Dr. Razavi's Good to Know Info

Mammography Debate - When to Start Screening

2010-10-17T13:04:00.000-07:00

At what age is it recommended for a woman to start routine mammograms:

A. 40 years old

B. 50 years old

C. Neither A or B

D. Both A and B.

Until last year, there was a uniform recommendation in the United States for women to start routine mammography for breast cancer screening at the age of 40 and then repeat every 1-2 years. However recently the US Preventive services Task Force (USPSTF) has issued new recommendations to start routine mammography screening at age 50, to repeat mammograms every 2 years between ages 50 - 74, and to end screening at age 74.

This recommendation is controversial. As a result there has been some confusion for both patients and physicians as to when a woman should consider getting her mammograms.

The USPSTF made their recommendation based on a review of published evidence of the efficacy of screening in lowering breast cancer mortality rates. These studies were identified through Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, MEDLINE January 2001 to December 2008. The reviewers found that film mammography is associated with reduced breast cancer mortality rates, especially in women 50 to 74 years old. Women aged 60 - 69 may have the greatest benefit. For women aged 40 to 49 years there was a 15% decrease in mortality.

However a new study from Sweden reports that mammography screening in women aged 40-49 years old showed a much greater reduction in mortality from breast cancer than has been previously reported. This data showed a 29% reduction in breast cancer mortality in this age group when screening was done. In this large study, more than 1 million women were involved, and they were monitored for 16 years. This study was done because of differences in counties in Sweden. Initially in 1986 Sweden targeted women aged 50 - 69 years but left it up to individual counties to determine if women 40 - 49 years old should be screened. About half of the counties invited women aged 40 - 49 years old to undergo screening and half did not. During the follow up period between 1986 - 2005, there were 619 deaths from breast cancer in women ho had been invited for screening, and 1205 deaths in women who had not undergone screening.

Currently in the U.S., most organizations recommend yearly mammograms beginning at age 40, including the American Cancer Society, the National Comprehensive Cancer Network, the American Medical Association, and the American College of Obstetricians and Gynecologists. It is only the USSPTF that does not recommend regular mammography in the 40 - 49 year age group.

For women between 40 - 49, it is best to speak with your physician. The decision may need to be made on an individualized basis. If a woman is considered to be at higher risk for breast cancer then an earlier mammography screening should be considered.

Answer - D.

Bedbugs Among Us

2010-09-12T17:31:00.000-07:00

Bedbugs are small insects (family Cimicidae) which are found around the world. Recently they have become particularly fond of New York.

Where do they hide?

These bugs can infest any location where people reside such as apartment buildings, offices, and public transportation systems. These reddish brown bugs which are similar in size to a dog tick can hide in multiple areas such as in cracks in walls or in electrical outlets, in crevices of mattresses, cushions and curtains, or in bottom of desk drawers and other pieces of furniture. The females may lay eggs daily in these same areas. It's hard to see the bugs unless one is looking for them. Often the first clue to their infestation appears on the skin as bite marks.

What do the bites look like?

The bites can be difficult to distinguish from other insect bites. They are usually a series of red, round, swollen, itchy, painless spots which are in a linear distribution (breakfast, lunch, and dinner) which may occur 1 - 2 days after being bitten. The reactions vary in severity depending on the sensitivity of the individual. The bugs find an exposed surface of skin such as on the arms, legs, neck or face, and then they proceed to inject an anesthetic and an anticoagulant through one tube while they suck up the blood through the other tube. Feeding time takes 5 - 10 minutes to be completed so it usually occurs while one is still for a period of time such as while sitting or sleeping. The satiated bugs then return to their hiding place.

How can the bites be treated?

It can take 3 - 6 weeks for the bites to heal. If the infestation is not cleared new bites may accumulate as the old ones heal. Steroid creams or lotions that contain pramoxine (such as Sarna, Aveeno Anti-itch, Neutrogena Skin-Aid) can help reduce the itching. Antihistamines (such as Zyrtec, Claritin/loratidine, Benadryl/diphenhydamine) may help reduce the severity of the reaction and also reduce itching. It is important to avoid scratching the area as this may lead to infection. If there are signs of infection such as pus-like drainage, pain or increased redness then a doctor should be consulted.

Do bedbugs carry any diseases?

This topic is currently under research. Hepatits B virus has been found in the droppings of bedbugs, but a higher incidence of the disease has not been associated with a bedbug infestation in the areas studied so far. In South and Central America, the bugs have transmitted the parasite Trypanosoma cruzi which causes Chaga's disease. There has also been some speculation about an association with these bugs and asthma in some countries. In general however bedbugs are not known for transmitting any widespread disease.

How to manage an infestation?

It is important to identify and eliminate the infestation. For effective eradication, it is recommended that a licensed pest control service be contacted to inspect and treat the area. There is no need to dispose of furniture once treatment has occurred. Clothing and linens can be adequately treated by washing and drying them in the hottest setting that the fabric can withstand.

If you would like to see these critters in action, here are some videos for you.

National Geographic Video on Bedbugs.

BedBugs! Attack!

Jon Stewart's piece on bedbugs.

For more details, see this bedbug fact sheet.

Who Needs the Flu Vaccine?

2008-10-19T14:06:00.000-07:00

Based on global surveillance of influenza strains, all 3 strains in the 2008 to 2009 influenza vaccines are different from the 2007 to 2008 vaccine strains. Let's hope that we haven't missed any significant ones this year.

In general anyone who would like to avoid the flu syndrome should get the flu shot. Certain groups of people are especially recommended to receive the vaccine yearly according the Advisory Committee on Immunization Practices (ACIP).

Children aged 6 months to 18 years.
Household contacts and out of home caregivers of children less than 6 months old.
Pregnant women.
People who are 50 years or older.
People of any age who have other underlying medical conditions such as asthma, diabetes, or malignancies.
Nursing home residents and anyone who cares for them.
Health care workers.

People who should not get the vaccine are the following:

Anyone who is severely allergic to eggs.
Anyone who has had an allergic reaction to a previous flu shot.
Anyone who has had a recent febrile illness (should wait until the fever resolves before getting the vaccine.
Anyone with a history of Guillan Barre within 6 weeks of having received the flu shot.
Children less than 6 months old.

Biggest misconceptions about the flu shot is that it can give you the flu. The vaccine in the form of the shot does not give you the flu. Rarely, it can give you mild aches and possibly a low grade fever for 1-2 days. The nasal spray form of the flu vaccine, however, can give you a mild case of the flu. There are no supplements such as vitamin C or D which have been shown to prevent the flu. Other than the flu vaccine, the most effective means of prevention and spread of the flu is washing your hands and staying home when you are sick.

So what did you learn? Which of the following statements is correct?

A. Flu shot is not necessary if you take plenty of vitamin D supplement

B. The flu shot can give you mild flu-like symptoms

C. The flu shot is recommended for all children 6 months and older.

D. Pregnant women should avoid the flu shot.

E. If you miss the shot and get the flu, you should still show up at your job and work your buns off.

The correct answer is C.

Blood Pressure Control - People or Technology for Better Outcome?

2008-09-08T18:27:00.000-07:00

Countries may vary widely in their capacity for management of hypertension, but in all cases the majority of hypertensive patients are inadequately controlled to a blood pressure (BP) goal of less than 140/90 mmHg.

In the U.S. only 35 percent of hypertensives are treated to goal. Although this is an improvement from a previous rate of 23% 10 years ago, it is still suboptimal. The goal for the Healthy People 2010 objective is 50%. Other countries are not doing much better. Europe has slightly higher rates of control but they also have a higher prevalence of high blood pressure (especially the Germans when compared to five other European Countries). China by last report had 8%, Taiwan 5%, and South Africa 14% of their hypertensives under optimal control. (uptodate)

The reasons for this level of poor control are multifactorial. There certainly is no shortage of pharmacological treatments nor is there a lack of published guidelines. However, the distribution of data alone does not lead to different outcomes. Hypertension is a chronic disease that does not have symptoms. It often requires significant lifestyle changes in addition to medications. Lifestyle changes are difficult to make and they are not a priority for many people. When lifestyle changes are made, then there may be non-compliance to medications. The physicians may not be aggressive enough or simply may not have enough time in their busy offices to advise or motivate patients regularly.

The burden of high blood pressure worldwide is high. "In 2004 the death rates per 100,000 population in U.S. from high blood pressure were 15.7 for white males, 51.0 for black males, 14.5 for white females and 40.9 for black females. From 1994 to 2004 the death rate from high blood pressure increased 26.6 percent, and the actual number of deaths rose 56.1 percent" according to the American Heart Association. It is estimated that the prevalence will increase with an aging population in the west and the adaptation of lifestyle choices such as fast food and increasing obesity in the developing countries.

Different strategies for improved management of hypertension are being evaluated. It is not surprising that a multidisciplinary intervention is most effective. In a recent study presented in JAMA , 778 participants with uncontrolled high blood were randomly assigned to three groups - usual care in clinic, home BP monitoring (with Omron Hem-705-CP bp cuff) and secure patient Web site training, or home BP monitoring, Web site training, and pharmacist care management through Web communications. These groups were studied from June 2005 to December 2007.

The patients in the latter 2 groups received training on how to use the web site (secure e-mail, refilling medications, viewing portions of their health records, use of the health library, and links to resources for lifestyle changes). The pharmacist group received a secure welcome message from the pharmacist which was also communicated to the patient's physician. The pharmacist had a telephone visit ( 1 hour) with the patient to review medications and risk factors. An action plan template designed for Web communication was then given to the patient. All feedback on the action plan was then done over the Web every 2 weeks. The pharmacist with the assistance of the physician would make specific recommendations.

Based on patient results, the data showed that compared to the usual clinic care group, the home BP monitoring plus the Web based service only group did not show a significant improvement in blood pressure control. However, the group with the Web-based pharmacist had a significant improvement over the other 2 groups with 25% more patients with optimal control. So neither people or technology but rather the intervention of both seemed to work best for this group of patients. It will be interesting to use this model in other chronic illnesses to assess the effectiveness of the model.

Finally it is important for the physicians to note that " the most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with and trust in the clinician. Empathy builds trust and is a potent motivator."

References: please see above links.

What did you learn?

1. What percentage of patients with high blood pressure who are under medical care in the U.S. are treated to a goal bp of less than 140/90 mmHg?

a. 23%
b. 35%
c. 50%
d. 8%

2. Web based services have been shown to be most effective for treatment of blood pressure when used in which of the following strategies?

a. Web services alone
b. Web services + home bp monitoring + ancillary health care provider
c. Web services + home blood pressure monitoring

Correct answers:
1. B
2. B.

Brain Stimulation Better Than Best Medical Therapy For Parkinson's

2008-09-06T20:07:00.001-07:00

Preliminary data from ongoing trials suggest that deep brain stimulation (DBS) may be superior to the best medical therapy (BMT) for Parkinson's. In one trial of more than 300 patients, ages 22 and older, who were randomized to DBS vs BMT, the data showed that motor functioning at 6 months improved by 35% with deep brain stimulation as opposed to 5% with best medical therapy. However adverse effects were more common in the DBS group - 40% in comparison to 11% in BMT patients.

The best medical therapy arm of the trial was discontinued since there was enough data to evaluate the primary outcome. The deep brain stimulation patients were then randomized to 2 groups to compare bilateral stimulation of the subthalamic nucleus (STN) and globus pallidus interna (GPI) which comprise part of the basal ganglia - the part of the brain which is integral in the control of movement, motivation and addiction. Stimulation of these specific areas may cause different outcomes in mood, cognition, and movement. More specific targeting of these areas eventually may help decrease the adverse effects. The results of this part of the trial will not be available until 2009.

Treatments for Snoring

2008-08-23T15:41:00.000-07:00

Treatment of snoring does not include which of the following

a. weight reduction
b. avoidance of alcohol at night
c. injection of botulin toxin into soft palate ( the back of the roof of the mouth)
d. placement of implants into the soft palate palate
e. peppermint oil inhalation

Snoring is a common condition. In the Wisconsin Sleep Cohort Study, habitual snoring was present in 44 percent of males and 28 percent of females between 30 and 60 years of age. Snoring may be associated with obstructive sleep apnea or it may be primary and not associated with any underlying conditions. It is caused by partial airway collapse with vibration of the upper airway. Most vibration of the soft tissues occurs at the level of the soft palate.

There are several treatments for primary snoring which are mainly for the benefit of the snorer's partner. Some of these treatments include the following.

1. Weight Loss - Obesity is thought to contribute to snoring by reducing the airway dimension.

2. Alcohol and Tobacco Avoidance - Alcohol worsens the condition by decreasing the tone in the pharyngeal muscles. The same is true of sleeping pills. Alcohol should be avoided for several hours before sleep. it is not clear how smoking contributes to sleep-disordered breathing - nightly nicotine withdrawal or increased nasal congestion may contribute.

3. Positional Therapy - Some individuals snore more when they are lying flat on their back.
Turning to a lateral position has been shown to decrease snoring in these snorers. A foam wedge can be used to maintain the position.

4. Medication - Nasal steroids can be used to decrease congestion. Protriptyline has been used but it may have side effects such as impotence.

5. Reducing Nasal Resistance - Mechanical devices may be used to dilate the anterior nasal valve. One that works well is a stiff adhesive strip that is applied externally across the nasal alae where it serves to retract and stabilize them.

6. Surgical Procedures - The newest technique which has been recently approved by the FDA is the placement of polyethylene terephthalate (PET) implants into the center of the soft palate to stiffen the area and to reduce fluttering. This procedure is less invasive and less painful than the traditional surgeries which include uvulopalatopharyngoplasty (shortening of the uvula and removing part of the soft palate) by scalpel or laser and radiofrequency treatment (which induces scar formation of the palate).

The correct answer is e.

Vitamin D in the Spotlight

2008-08-12T14:00:00.000-07:00

Vitamin D supplementation (finish the sentence correctly)

a. is usually not necessary as it is found in most foods
b. causes rickets, a bone disease
c. may protect against cancer
d. all of the above
e. none of the above.

The correct answer is C. Vitamin D has has received much attention recently. Several studies have reported an array of health benefits associated with vitamin D in children and in adults, possibly protecting against cardiovascular disease, certain cancers, and immune system disorders such as rheumatoid arthritis. These data have generated debate over the daily amount of vitamin D that should be recommended.

The current recommendation is 200 to 600 international units (IU) daily, depending on age. New data has emerged to question this guideline. There are very few food sources of vitamin D, namely fatty fish and eggs. Most of our vitamin D is synthesized in our skin through a process that requires sunlight. However, due to more sedentary lifestyles such as long working hours, web surfing, and playing video games, and heeding advice to avoid the sun to prevent skin cancer the level of vitamin D may be lower than our body requires. Some even suggest a worldwide pandemic of vitamin D deficiency.

It is well established that vitamin D deficiency causes rickets, a bone disease which usually affects children, in which the bones become very soft. See Dr. Janesta Noland's post on this blog regarding new vitamin D recommendations for children.

Additional benefits have been suggested for adults. In one study, vitamin D supplementation of 800 IU daily was associated with a decreased risk of colon cancer. This was shown to occur as a result of the expression of Bax - a protein that promotes the killing of damaged cells. In three meta-analysis observational studies, a serum 25-hydroxyvitamin D level of 30 ng/ml (75 nmol/L) or higher was associated with at least a 50% lower risk of breast cancer. As a result it has been suggested that women should be checked annually for vitamin D level to better identify their risk of breast cancer. A study funded by the National Institute of Health showed that women who took 1100 IU per day of vitamin D for 4 years reduced their risk of breast cancer by 60 percent.

Bottom line is that although it is not yet an official recommendation, based on recent studies, there may be a benefit to taking between 1000-2000 IU per day of vitamin D.

References: see above links. Am. J. Clinical Nutrition, 2007; 85:1586-91

New Vitamin D Recommendation for Children

2008-08-11T23:13:00.000-07:00

Dr. Janesta Noland, our guest pediatrician blogger, has provided a summary of the new recommendation for vitamin D supplementation in children.

New data reveal many ways in which vitamin D is important in overall health and prevention of disease requiring higher levels than those which cause clinically evident rickets. Additionally, data show that the previously recommended 200 IU daily will not maintain levels above 11ng/ml in a significant proportion of children. As a result of these findings on dose and medical importance of vitamin D, the American Academy of Pediatrics (AAP) is changing its recommendation to a higher dose of 400 IU daily in all infants, children and adolescents not taking 1000mL (33oz.) daily of fortified formula or milk.

For lots (and I mean lots) more detail on vitamin D read on....

The American Academy of Pediatrics has recommended since 2003 that all breastfeeding infants be supplemented with 200 IU of vitamin D daily1. Vitamin D is essential in calcium absorption in the gut and in bone metabolism including growth and remodeling. Vitamin D production occurs in the skin after exposure to UVB radiation and is affected by latitude, air pollution, time in the sun, season, cloud cover, body mass and amount of body exposure. Dietary sources of vitamin D are not generally significant: the only foods that contain meaningful amounts are fatty fish, fish oils, liver, fat from marine mammals and eggs from chicken fed vitamin D.

For current typical lifestyles, and given recommendations by the AAP and American Cancer Society to avoid sun exposure because of the risk of skin cancer, children may not have adequate levels of vitamin D. Profound deficiency of vitamin D can cause rickets and continues to be reported in the US despite the current recommendations. The peak incidence is between 3 and 18 months of age. The risk is higher in infants who are exclusively breastfed and infants with darker skin pigmentation.2,3,4,5,6,7

Long before vitamin D deficiency rickets is evident, insufficiency may occur and may appear as growth failure, lethargy, irritability, and hypocalcemic seizures8,9,10. New evidence in adults suggests that vitamin D also plays a role in preventing autoimmune disease such as rheumatoid arthritis11 and multiple sclerosis12, some forms of cancer13,14,15,16,17,18,19,20,21 (breast, ovary, prostate and colorectal) and may diminish the incidence of Type 2 diabetes22,23,24. Some evidence in children suggests vitamin D supplements in infancy may decrease type 1 diabetes25,26,27.

Vitamin D must by hydroxylated in the body to be active. Serum levels of 25[OH]vitamin D are the best indicator of vitamin D status. The level of vitamin D in the blood that constitutes deficiency has only recently been defined for adults (12-15 ng/ml and insufficiency at <20>

Given the now better-understood risks of vitamin D insufficiency in children that precedes the development of clinically evident rickets, supplementation with vitamin D is important. 400 IU daily is known to be safe, and both prevent and treat rickets. An AAP clinical report is in press32 which will establish this new recommended dose which should be initiated as soon as breastfeeding is well established.

All infant formula in the US is fortified to 400 IU per liter (about 33 ounces). Exclusively formula-fed infants who take this amount of formula do not need supplementation. However, infants who are breastfed or who are taking both formula and breast milk require supplementation.

Vitamin D can be taken in two forms: ergocalciferol (D2 – plant-based) or cholecalciferol (D3 – fish-based). D3 has greater efficacy in raising serum levels33 and thus is the recommended and most commonly used form. It is available both in multivitamin form and alone in liquid or drops. (Because of the potential for overdose with the concentrated drop form, liquid is recommended.)

The vitamin D status of pregnant and lactating mothers greatly impacts vitamin D levels in their infants. Fetal vitamin D levels appear to have both short and long-term consequences – one study showed an increase in birth weight when mothers have levels above 20 ng/ml34, and another showed increased bone density in 9 year old children whose mothers were supplemented during pregnancy35. No consensus exists on the dose of vitamin D supplementation in these women, despite the fact that studies show that on average pregnant women are deficient without supplementation (13 ng/ml in one study and <10>

The Canadian Paediatric Society recommends 2000 IU daily for pregnant and breastfeeding women31. Two pilot studies of high-dose vitamin D supplementation in lactating mothers (6400 IU) showed serum levels in their infants equivalent to levels in infants taking 300-400 IU supplements41,42. Safety of the long-term use of such high levels of supplementation in women has not been studied, however, and cannot be recommended. Since vitamin D deficiency is not limited to infancy but persists throughout the lifespan, particularly during phases of rapid growth, supplementation is important in children and adolescents as well. Consumption of 32oz/day of vitamin D fortified milk would provide the required 400 IU, but dietary practices make that difficult to achieve. Thus a multivitamin with 400 IU of vitamin D is appropriate.

Excellent links:

http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/908(This is the old policy – new is in press)

http://www.nih.gov/news/pr/aug2007/od-17.htm http://ods.od.nih.gov/factsheets/vitamind.asp

Bibliography
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3. Pettifor J. Nutritional rickets: deficiency of vitamin D, calcium, or both? Am J Clin Nutr 2004;80(suppl):1725S-1729S
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35. Wagner C, Hulsey T, Fanning D, Ebeling M, Hollis B. High dose vitamin D3 Supplementation in a cohort of breastfeeding mothers and their infants: A six-month follow-up pilot study. Breastfeeding Medicine 2006;2(59-70).
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37. van der Meer I, Karamali N, Boeke A. High prevalence of vitamin D deficiency in pregnant non-Western women the The Hague, Netherlands. Am J Clin Nutr 2006;84:350-353.
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Chronic Fatigue Syndrome

2008-08-03T22:08:00.000-07:00

According to the CDC, chronic fatigue syndrome (CFS) is defined by the presence of:
unexplained, persistent fatigue that is of new onset; is not the result of ongoing exertion; is not alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities AND

a. impairment in short term memory or concentration
b. sore throat or tender lymph nodes in the neck or under the arms
c. muscle pain or multijoint pain without redness or swelling
d. headache of a new pattern or severity
e. 2 of the above
f. 4 of the above

Correct answer is F - chronic fatigue syndrome is diagnosed by persistent fatigue and the presence of four or more of the above symptoms that persist during six or more consecutive months and that have not been present prior to the onset of the CFS. Other symptoms which are also included in making the diagnosis are unrefreshing sleep, low grade fever or post-exertional malaise lasting more than 24 hours.

Patients who have chronic fatigue but who do not have these criteria are defined as having idiopathic chronic fatigue. Less than 10 percent of patients who complain of fatigue meet the criteria for CFS. It is twice as more likely to occur in women.

CFS is a difficult diagnosis to make due to the lack of physical or laboratory findings. The history is the most important part of the evaluation. Simple blood tests for blood count, thyroid, sugar, kidney and liver function and HIV and tuberculosis may be done to rule out other causes, but in general more extensive testing for conditions such as Lyme disease or EBV (Epstein Bar Virus) is not recommended.

The cause remains unclear. From the 1930's to the 1950's, the cause was assumed to be due to chronic brucellosis infection, and from 1950's to 1970's it was hypoglycemia. More recently research has focused on chronic Epstein Barr virus (EBV) infection, Lyme disease, allergies, candidiasis, and immune system disorders. However, scientific data does not support any of these hypotheses. Another controversial factor is the role of depression in this condition. Three studies verified that two-thirds or more of patients with CFS meet criteria for anxiety disorders or depression. However, it is debated if this is a primary cause or a secondary symptom as a result of chronic fatigue.

Several treatment strategies including multiple medications have been tried, but the only regimens which have been shown to have a positive impact are cognitive behavior therapy (CBT) and graded exercise therapy. The behavior therapy consists of a series of one hour sessions designed to modify behavior that may delay recovery. Support groups were not as beneficial as individual sessions. Ideally this is done in combination with exercise therapy. Although exercise can initially worsen the symptoms, it is not advised to increase rest. Patients are encouraged to gradually push themselves by doing cardiopulmonary exercises such as walking on a treadmill. Finally another important factor in long term treatment management is the rapport that exists between the physician and patient.

Patient resources: Center for Disease Control, National CFS and Fibromyalgia Association, Up To Date Patient Information.

References:
The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group.
Psychiatric diagnoses in patients who have chronic fatigue syndrome.
Interventions for the treatment and management of chronic fatigue syndrome: a systematic review.
Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial.

New Blood Pressure Guidelines

2008-07-29T19:01:00.000-07:00

Normal blood pressure reading in an adult is

a. systolic less than 110 / diastolic less than 80 millimeters of mercury (mmHg)
b. systolic less than 120 / diastolic less than 80 mmHg
c. systolic 120-139 or diastolic 80-89 mmHg
d. systolic 140-159 or diastolic 90-99 mmHg

The correct answer is b. The seventh report of the Joint National Committee(JNC 7) proposed a new range for normal blood pressure (less than 120/80) and a new category of prehypertension. This recommendation was based on several studies, completed since the 6th JNC report in 1997, which showed a strong correlation between increasing blood pressure and an increase in heart attacks, cardiovascular disease, stroke, and kidney disease.

An analysis of data from the Framingham Heart Study demonstrated that relative to blood pressure less than 120/80 mmHg, prehypertension (120 to 129/80 to 84 mmHg) was associated with an increased risk of heart attacks (relative risk 3.5) and coronary artery disease (relative risk 1.7), but not stroke. In the Women's Health Initiative study involving over 60,785 postmenopausal women who were followed for 7.7 years, women with prehypertension, compared to normotensive individuals, had an increased risk of cardiovascular death, myocardial infarction and stroke. The risk of cardiovascular disease beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg.

Data from the 1999 and 2000 National Health and Nutrition Examination Survey (NHANES III) suggested that the prevalence of prehypertension among adults in the United States was approximately 30 percent. The prevalence was markedly higher among men than women (39 and 23 percent, respectively). Lifestyle modifications and a closer monitoring is recommended for these patients. Medications may be necessary if other risk factors are present. According to JNC7, a blood pressure of systolic 140-159 mmHg or diastolic 90-99 is classified as stage I hypertension, and a medication should be started for these patients. Stage II hypertension is categorized as systolic more than 160 mmHg or diastolic more 100 mmHg. These patients will usually require two medications for control of the blood pressure in addition to making the lifestyle modifications.

For more information on lifestyle modifications and medication management see JNC 7 report.
Note that the European Recommendations have chosen to continue the same guidelines as the JNC 6 report.

Is Your Sugar Level Normal

2008-07-21T21:23:00.000-07:00

A normal fasting glucose (sugar) level is above 69 mg/dl (milligram per deciliter) or 3.9 mmol/L (millimoles/liter)and less than

a. 140 mg/dl (7.8mmol/L)
b. 125 mg/dl (7.0 mmol/L)
c. 110 mg/dl (6.1 mmol/L)
d. 100 mg/dl (5.6 mmol/L)

The correct answer is d. A normal fasting glucose level is between 70 - 100 mg/dl (3.9-5.6 mmol/l) . This level was established by the American Diabetes Association (ADA) in 2003. Previously a cut off point of 110 mg/dl was considered to be normal. Those of you who have had glucose levels in that range and were told that your level was normal should consider getting an updated glucose check.

Levels between 100-125 mg/dl (5.6-7.0 mmol/l) are termed as "impaired fasting glucose". These patients may have a three fold increase in risk of diabetes. Lifestyle changes such as weight loss, physical activity and a low sugar diet are recommended to improve these numbers.

Diabetes is defined as glucose level above 125 mg/dl (7.0 mmol/l). The level was reduced from 140 to 125 in 1997. The ADA recommends testing for glucose in all adults with BMI ≥25 kg/m2 and one or more additional risk factors for diabetes. There are several risk factors for diabetes. These include age of 45 years or older, body mass index of 25 kg/m2 or higher, family history of diabetes, physical inactivity, ethnicity of African-American, Hispanic, Native American, Asian-American, and Pacific Islanders, delivering a 9 lb or larger baby, high blood pressure (>140/90), abnormal cholesterol level (HDL <35,>250), and polycystic ovary syndrome. In individuals without risk factors, testing should begin at age 45 years.

Video tutorial on diabetes: Dr. Jerold Olefsky.

What are mg/dl and mmol/l? How to convert? Glucose? Cholesterol?

2008-07-21T07:05:00.000-07:00

There are two main methods of describing concentrations: by weight, and
by molecular count. Weights are in grams, molecular counts in moles. (If you
really want to know, a mole is 6.023*10^23 molecules.) In both cases, the
unit is usually modified by milli- or micro- or other prefix, and is always
"per" some volume, often a liter.

This means that the conversion factor depends on the molecular weight of the
substance in question.
mmol/l is millimoles/liter, and is the world standard unit for measuring
glucose in blood. Specifically, it is the designated SI (Systeme
International) unit. "World standard", of course, means that mmol/L is used
everywhere in the world except in the US.

mg/dl (milligrams/deciliter) is the traditional unit for measuring bG (blood
glucose). Most discussions take place using mg/dl, and no one really
expects you to pull out your calculator to compose your article. However, if
you don't quote both units, it's inevitable that many readers will have to
pull out their calculators to read it. ( I learned this the hard way).

To convert mmol/l of glucose to mg/dl, multiply by 18.
To convert mg/dl of glucose to mmol/l, divide by 18 or multiply by 0.055.

mmol/l ---mg/dl--- interpretation
2.0 -------35 ------extremely low, danger of unconciousness
3.0 -------55 ------low, marginal insulin reaction
4.0 -------75 ------slightly low, first symptoms of lethargy etc.
5.5 -------100 -----mecca
5 - 6 ---90-110 ----normal preprandial in nondiabetics
8.0 ------150------ normal postprandial in nondiabetics
10.0 -----180------ maximum postprandial in nondiabetics
11.0 -----200
15.0------270------ a little high to very high depending on patient
16.5 ------300
20.0 -----360------ getting up there
22 -------400------ max mg/dl for some meters and strips
33 -------600 ------high danger of severe electrolyte imbalance

More conversions:
To convert mmol/l of HDL or LDL cholesterol to mg/dl, multiply by 39.
To convert mg/dl of HDL or LDL cholesterol to mmol/l, divide by 39.
To convert mmol/l of triglycerides to mg/dl, multiply by 89.
To convert mg/dl of triglycerides to mmol/l, divide by 89.
To convert umol (micromoles) /l of creatinine to mg/dl, divide by 88.
To convert mg/dl of creatinine to umol/l, multiply by 88.

post courtesy of FAQs.org

Got Sexually Transmitted Diseases?

2008-07-14T20:27:00.000-07:00

The most common sexually transmitted disease in the United States is

a. Human papilloma virus (HPV)
b. Chlamydia
c. HIV
d. Gonorrhea
e. Trichomonas

The correct answer is B. Chlamydia is the most common sexually transmitted disease (STD) in the United States. Each year there are 19 million new cases of sexually transmitted diseases in the U.S. Chlamydia, HPV and trichomonas account for 88% of these infections.

The danger of chlamydia is that it may not cause any symptoms. It is asymptomatic in 80 percent of women and in 50 percent of men who have an active infection. If there are symptoms - burning, itching - they may go away on their own while the bacteria remains in the body. If left untreated Chlamydia may lead to several complications. In women it can cause pelvic inflammatory disease (PID). This is a condition in which the bacteria travel up the vagina to the uterus and to the fallopian tubes causing scarring, chronic pelvic pain and sterility. In men it can cause prostatitis (inflammation of the prostate), urethral scarring and infertility.

Chlamydia can be detected by a urine test in men and women or during a pap test in women. It is recommended for all sexually active women under 25 to be screened for chlamydia annually. If the patient is African-American then a screening for gonorrhea is also recommended.

Once detected chlamydia is easily treated with antibiotics - doxycycline 100 mg twice daily for 7 days or azithromycin 1 gram once. The partner of the patient must also be treated. In fact according to new guidelines it is advised for the doctor to give extra doses of antibiotics to the patient so that he or she could distribute it to the partner. This is one of the few exceptions in medicine when a doctor may prescribe a medication without seeing the patient. The rationale for this strategy is that it will increase cure rate.

All infected individuals should be re-screened in 3 months after treatment.

Ideally of course it would be best for each person to be have an STD screening before having sex with a new partner. If you are intimate enough to have sex then you should be comfortable enough to have the STD discussion. If you do not have a regular doctor, the test may be obtained at any planned parenthood or county facility.

If you have any STD related questions, you can email Dr. Jeffrey Klausner at Ask Dr. K. Another resource is SEXINFO, a texting service from the San Francisco Department of Health.

When Should Cholesterol Screening Start

2008-07-07T21:33:00.000-07:00

At what age do you think that routine cholesterol testing should begin?
a. age 2
b. age 16
c. age 25
d. age 30

According to new recommendations by the American Academy of Pediatrics, the correct answer is A. Screening is advised to begin at age 2 and no later than age 10 for children who have a family history of high cholesterol or, or a family history of early heart disease (age 55 or younger in a male parent or grandparent, age 65 or younger for female first and second degree relatives.). Other children who should be screened regardless of family history are those who are overweight (at or above the 85th percentile), or who have risk factors such as, diabetes, or high blood pressure.

Children under age 2 should not be screened. If the fasting lipid profile is normal, a child should be screened again in three to five years. If the cholesterol level is high and the child cannot lower it by lifestyle changes in 6 to 12 months, then it is recommended to start medications such as statins to lower the cholesterol level. Normal cholesterol levels are different for children. Total cholesterol should be less than 170 and the LDL cholesterol should be less than 110.

The rationale for these guidelines is that atherosclerosis which leads to heart disease starts very early in life. With 30 percent of young Americans considered overweight or obese there is a rising concern that there will be an epidemic of heart attacks and strokes when these children reach adulthood. Although it will be controversial to start children as young as 8 on drug therapy, the Academy argues that research has shown that these medications are safe in children and that the benefit of starting the treatment earlier outweighs any potential risks.

Reference: "Lipid Screening and Cardiovascular Health in Childhood."Stephen R. Daniels, Frank R. Greer, and the Committee on Nutrition.PEDIATRICS Vol. 122 No. 1 July 2008, pp. 198-208

Fracture Risk Calculator

2008-07-01T18:25:00.000-07:00

How likely is it for you to sustain a fracture in the next 10 years? A new algorithm tool has been developed by the World Health Organization (WHO) to help assess your risk of fractures and osteoporosis.

Osteoporosis is a deterioration of bone mass (porous bone) which leads to fractures of wrist, hip and spine. It is usually measured by a radiological test called the bone-mineral density test. Treatment may be indicated depending on the amount of bone loss detected.

The new tool called the "FRAX" calculator may be used with or without the results of a bone-mineral density test. The model incorporates other clinical criteria such as age, sex, body-mass index, and seven other risk factors to predict the 10 year risk of fractures. Investigators analyzed data from multiple large international population-based studies to develop this statistical model which should add to the accuracy of the bone-mineral density test and better guide the use of medications used for prevention of fractures.

Sudden Cardiac Death

2008-06-24T17:57:00.000-07:00

Tim Russert’s unexpected passing from a heart attack served as a solemn reminder that heart disease is an important topic for everyone to know about. Sudden cardiac death accounts for 310,000 deaths a year in the United States. It occurs after a heart attack ( caused by a blockage in an artery that supplies the heart) or an enlarged heart (caused by infections or congenital diseases) results in a life-threatening, abnormal heart rhythm. When this happens, the heart is unable to effectively pump blood out to the body and maintain life. Defibrillators are used to convert the abnormal rhythm to a regular one. A quick response is essential for survival. As a result, defibrillators are now found in many locations such as schools, office buildings, and airplanes.

Certain risk factors contribute to heart disease. These include high cholesterol, high blood pressure (above 140/90), diabetes, being overweight (BMI greater than 25), smoking and not exercising. Other risk factors which we are unable to control include having a family history of heart disease or sudden cardiac death, male gender, increased age or being a postmenopausal female. Although risk factors exist, the condition can still not be fully prevented. Inform your physician about any feelings of discomfort which you may have in your chest, jaw or abdomen that is made worse with exertion and is relieved with rest.

Blog: courtesy of Dr. Roger Kapoor.
Refernces: please see links.

Reliable Medical Resource

2008-06-19T21:30:00.000-07:00

Technology is a good thing. Information is more and more accessible - after all that is Google's mission - but reliability of the information is not easily determined. I appreciate patients educating themselves about their medical conditions. However, there are times when they would have been been better off without doing the online research. Not all information is good information and content out of context can be confusing.

So for your benefit and for your overworked doctor's reassurance, here's a link which is worth checking the next time you need to get information on an ailment. The link was recently made available by Up To Date - an evidence based information source normally provided for physicians only. Many physicians rely on this service which is available to them for a fee, however, the patient information section is free.

Tainted Tomatoes

2008-06-09T10:53:00.000-07:00

Tomatoes have been identified as the source of salmonella poisoning in 145 people in several states in the US over the last 2 months. It is best to avoid Roma and round red tomatoes. Tomatoes that are considered safe to eat are cherry tomatoes, grape tomatoes, tomatoes that are still on the vine, and home grown tomatoes.

For updates see this Food and Drug Administration page.

You may recall this review from a previous contamination that involved spinach.
Salmonella is a bacteria that is transmitted to humans by eating foods that are contaminated by animal or human feces. It does not cause any change in the smell or taste of the food that it infects. It is the most frequently reported cause of food borne illnesses in the US - 1.4 million cases annually.

Symptoms of salmonella infection include diarrhea, cramps, fever, and vomiting. The symptoms may be much more severe in young children, the elderly, and in the immunocompromised patients. Although the illness may resolve spontaneously after 7 days, it may take several months before the bowels return to normal. A small percentage of the people may also develop joint pain, painful urination, and eye irritation that may last for months to years.

Seizures

2008-06-02T11:10:00.000-07:00

Senator Ted Kennedy is undergoing surgery for a brain tumor today. The first indication that a pathology was involved was his recent episode of a seizure. The events that lead to his recent diagnosis are important to understand.

What exactly is a seizure and why does it happen? A seizure occurs when our brain has an abnormal electrical signal, similar to an unexpected, sudden burst of lightening. The particular area of the brain involved dictates what symptoms someone might experience from uncontrollable shaking (muscle spasms) to staring spells to a loss of consciousness. The term epilepsy describes someone who has many seizures. Much like a fever is our body’s way of telling us that something is not right, a seizure is our brain’s way of raising a red flag. An abnormal electrical signal can be sent as a result of any of the following reasons: injury to the head, brain infection, brain tumor or stroke. In addition, anything that disrupts the environment our brain cells live in can also cause them to become irritated and result in a seizure: low blood sugar, drug use (cocaine etc), alcohol withdrawal or very high fevers.

So, besides calling a health care professional, what do you do if someone is having a seizure? In general, not interfering with a seizure is often the right thing to do. Remember that a seizure is completely involuntary, so don’t try to stop a person from shaking or place anything in their mouth. However, if the person starts to show signs of vomiting, quickly turn them to their side so that they able to expel everything that comes out of their mouth (swallowing it might result in lung damage). You can also attempt to place a cushion under their head to prevent them from repeatedly hitting their head on the floor. Try to move all objects away from the person so that they can do less harm to themselves – create as much space around the individual as you can. After a seizure, the person will likely be in a deep sleep, disoriented or agitated. Whatever the situation, most seizures are self-limiting and you should refrain from giving the individual anything to eat or drink until the person is completely alert and oriented.

Blog: courtesy of Dr. Roger Kapoor.
References: please see links.

Promising Early Lung Cancer Detection

2008-05-27T21:51:00.000-07:00

I went to a funeral of a dear patient today. I had taken care of her for 15 years. She was 72 years old, she was married for 54 years, and she had one son. She loved to play golf, to over-decorate the house for the holidays, and to spend time with her family. But she also loved to smoke her cigarettes despite our many discussions about the risks of smoking.

She had been fine until 3 months ago when she presented with abdominal pain. Shortly thereafter she was diagnosed with widespread lung cancer that was growing by the day. Six weeks is all that she had from the time of her lung biopsy to her death.

Lung cancer scares me because I know that no matter how complete a physical exam or how many tests that I perform, there is a chance that it may still be awaiting my patient. Lung cancer kills more people around the world than any other cancer. 10 million new lung cancer diagnoses are made each year. Most of these cases are diagnosed too late in the course for effective treatment. Over three quarters of all lung-cancer patients are/were long-term regular smokers. The only means of diagnosing lung cancer is by chest xray or chest CT scan. Neither of these tests is effective in detecting the cancer at an early stage.

A recent study in the Journal of Thoracic Oncology, however, has concluded that a blood test may be able to predict early non-small cell lung cancer with an accuracy rate of 87%. The cancer may be present 3-5 years before it is detected on the imaging tests. Although it is too late for this particular patient, there is promise that others may have a chance of earlier detection and therefore of cure of lung cancer by a simple blood test. More studies will be needed to better define the role of this technology in clinical context.

In the Emergency Room

2008-05-11T23:59:00.000-07:00

An ambulance comes to a screeching halt in front of the Emergency Room (ER). With its sirens still blaring, a short ride on a gurney separates the patient from the ER. Hopefully, you will never be in the scenario where you or someone you care about goes to the ER, but just in case, there are a few good things to know. Dr. Roger Kapoor, one of Stanford Hospital's best medical interns, shares his insights with us.

Being prepared may be the single best thing you can do. What do I mean? There are a few pieces of information every ER physician will want to know and having a piece of paper such as this completed can not only help physicians care for you quicker but also facilitate a higher quality of care.

What can you expect when you come to the ER? Expect to wait! If you come in an ambulance, you will immediately be taken to an emergency room bed. If not, the ER is run on a triage system ensuring the sickest patients are seen first. After registering, you will be seen by a triage nurse who will ask you questions regarding what brought you to the ER and then you will return to your seat in the waiting room. When it is your turn you will be escorted from the waiting room to your emergency room bed. Typically, your room will include a little monitor used to follow your heart rate, breathing and blood pressure. Your room will not have much space and drapes will likely separate it from the next bed. Don’t be surprised if the ER is so busy that instead of a room you are simply asked to sit in a gurney in the ER hallway. You may be asked to remove your clothing and wear a hospital gown.

After you have settled in and a nurse has asked you some additional questions, a resident doctor (a doctor in training who has graduated from medical school and who does not typically look like George Clooney in "ER") usually speaks with you first and evaluates your issue. He or she will ask you several questions about your condition. After your initial evaluation, physician orders will be placed to further investigate what is causing your discomfort. This might include obtaining an X-ray, putting in an “IV” or intravenous line and obtaining blood and urine samples. Here is a list of medical jargon that you might hear while you are in the ER. If someone says something you don’t understand, don’t be afraid to ask questions. At every point during your evaluation, you have the right to refuse any treatment or method of evaluation that you are uncomfortable with.

The ER resident will present your case to the attending ER doctor (the supervising doctor over-seeing all care provided in the ER). The attending doctor then speaks with you, confirms your issues and gives you her impression of what is likely happening. The resident doctor will continue to check in with you frequently, updating you on lab study results, imaging studies and any changes in your treatment plan.

If your issue demands specialist attention, the ER doctors have the ability to enlist the aid of any specialty (heart doctors, ob/gyn doctors, surgeons etc.). In this manner, it is possible that you could see many faces during your ER visit. It is a very good idea to write down the names of people who come to see you and what specialty they are with. The majority of people who come to the ER are able to leave (perhaps with a prescription for medications or instructions on how to get better). Some patients are admitted to the hospital for further care and evaluation.

Finally, it is important for your primary care doctor to be notified of your arrival in the ER. The staff or a family member should call your doctor. He or she will be able to provide pertinent information to the ER staff to guide your medical care in the most optimal way possible.

Blog: courtesy of Dr. Roger Kapoor.

I will be on vacation from the blog for the next 2 weeks. In the meanwhile, please take time to fill out the first document in this post " My Medical Information ".

Smoking, Mortality, Reversal

2008-05-07T23:09:00.000-07:00

Time to quit cigarettes is now. The craving may last a year or two but the damages sustained from smoking may take 20 years to reverse completely. According to a study from Harvard and Washington University School of Medicine, the excess risk of death in female smokers who have quit cigarettes decreases rapidly for vascular causes and in 20 years for lung disease.

This study assessed the relationship between cigarette smoking and smoking cessation on total and cause-specific mortality in women. More than 100,000 women were evaluated from 1980 to 2004. In this cohort, there were 12 483 deaths, of which 4485 (36%) were among never smokers, 3602 (29%) were among current smokers, and 4396 (35%) were among past smokers. Causes of mortality were categorized into vascular and respiratory diseases, lung cancer, other cancers, and other causes.

Compared with never smokers, current smokers had an increased risk of total mortality and all major cause-specific mortality. Approximately 64% of deaths among current smokers and 28% of deaths among former smokers were attributable to cigarette smoking. In addition there was a significant association between an earlier age of initiating smoking and all smoking-related cancer deaths. A trend was seen between smoking and colorectal cancer but not with ovarian cancer mortality.

A similar study is being done in a population of men. However, chances are that the results will not be very different from the findings in this study. If you are smoking now, stop. The body will start reversing the damages rapidly but it may take 20 years to reach the level of a person who has never smoked.

Resources to stop smoking.

References: JAMA. 2008;299(17):2037-2047.

Digitek Digoxin Tablets Recalled

2008-05-06T15:01:00.000-07:00

Digitek Digoxin tablets have been recalled by the manufacturer because they may be carrying double the normal dose. Digoxin is used in the treatment of arrhythmias and heart failure. The higher dose can cause serious toxicity especially in patients who have kidney disease. Symptoms of toxicity include nausea, vomiting, dizziness, weakness, decreased heart rate or arrhyhtmia and possibly death.

"Any customer inquiries related to this action should be addressed to Stericycle customer service at 1-888-276-6166 with representatives available Monday through Friday, 8 am to 5 pm EST. Additional information about the voluntary recall can also be found at www.actavis.us."

References: U.S. Food and Drug Administration.

Photo: courtesy of usrecallnews.

Heart Attack Questions

2008-05-04T23:42:00.000-07:00

A 47 year old heart attack survivor has asked me to help him educate others on how to recognize and manage symptoms of heart disease involving coronary artery disease which may lead to heart attacks. Twenty percent of people who suffer their first heart attack, die from this event. Many may have warning symptoms but do not recognize them. Others may have questions which are not fully answered during their visits with their physicians. This website is intended to review some of the most frequently asked questions about heart attacks.

Please let me know if you have any other questions that you feel would be useful to include in this site.

Flu Vaccine For Children

2008-04-27T16:49:00.000-07:00

One last thing on the flu. In a follow up to the previous post, our pediatric consultant, Dr. Janesta Noland, would like you to know that there is a new recommendation for flu vaccine for children.

The Advisory Committee on Immunization Practices (ACIP) unanimously voted at its winter meeting to expand recommendations for flu vaccinations to include children age 5-18 years. Previously, the vaccine was recommended for all children ages 6 months to 5 years as well as children of any age with high risk conditions such as asthma, cardiac disease or diabetes. Although the vote was unanimous, the decision about when it should go into effect was not. If practitioners were to implement the recommendation in the 2008-2009 influenza season, supplies of vaccine would likely be inadequate.

In the very youngest - children aged 6 to 23 months - vaccination prevents hospitalization in 74% of those who are fully immunized. (Of note, in children who do not receive the second dose of the vaccine, hospitalization is prevented in only 39%.) Although death or hospitalization is much less likely in healthy school-age children compared to younger children or children with high-risk conditions, 10-30% of children are afflicted with influenza illnesses annually which results in a large number of missed school days. And 5-7% of those aged 5-18 years visit the doctor for influenza each year and many receive antibiotics unnecessarily.

For parents to decide whether to vaccinate their children for influenza, they must weigh the likelihood of being infected with influenza, the predicted efficacy of the vaccine, risk of side effects of the vaccine, and the risk of going to the doctor, receiving antibiotics or missing school, or having more serious complications of flu resulting in hospitalization or death.

What About Thimerosal in Vaccines?

Thimerosal (a mercury-containing preservative) has been removed from nearly all pediatric vaccines because of concerns about a possible relationship between mercury and autism. These concerns could be the subject for a 12-volume dissertation so we will leave that for another discussion. It should be noted, however, that the current ACIP recommendations are that all children less than 36 months should receive thimerosal-free vaccine when supplies are adequate. Many pediatricians provide preservative-free vaccine exclusively, even for children older than 3 years. Ask your child’s doctor.

Flu Season Update

2008-04-22T16:21:00.003-07:00

This year's flu season has been the worst one that we have had in 4 years. The flu cases peaked in mid-February, but they continue to be reported throughout the states. According to the MMWR, this season " Pneumonia and influenza was listed as an underlying or contributing cause of death for 8.9% of all deaths reported for the week ending April 5, 2008. This percentage was above the epidemic threshold of 6.9% and marked the thirteenth consecutive week that the proportion of all deaths attributed to pneumonia and influenza was above the epidemic threshold."

The severity of this year's flu season is attributed to the decreased efficacy of the vaccine. The vaccine did not match some of the most virulent strains which were circulating this year. It was only 44% effective instead of the usual 70-90% effective. However, even at its lowest matching rate, the vaccine still offers some protection. Of the 67 children who died this year of the flu, more than 40 were not vaccinated.

References: please see links.

Laser Vision Correction - Are You a Candidate?

2008-04-15T15:12:00.000-07:00

Many people are interested in laser vision correction so that they can do away with their glasses or contact lenses. LASIK (laser-assisted in situ keratomileusis) and PRK (photorefractive keratotomy) are two of the most common techniques used for this type of vision correction. During these procedures, the cornea is reshaped to improve the eye's focusing power. Although the majority of patients are pleased with their results and may achieve 20/20 vision, no one can promise that you will be able to "throw away your glasses" after surgery.

Understanding the limitations of refractive surgery and having a realistic expectation is an important factor for a successful outcome. Your suitability for the procedures can be determined following a comprehensive eye examination. At that time, special measurements of the eyes will be performed. If you wear contact lenses, you should discontinue them for at least 2 weeks (soft contacts) or 4 weeks (gas permeable or hard lenses) before the examination, since contact lenses can interfere with obtaining accurate measurements.

The amount of correction that has been approved for treatment is between -1.0 and -10.0 D for nearsightedness (myopia), between 0.75 and 4.0 D for astigmatism, and between + 1.0 and 4.0 D for farsightedness (hyperopia). Presbyopia, the natural aging process of the eye, which causes the need for reading glasses after the age of 40 cannot be corrected by these procedures. You may be a candidate for LASIK or PRK if you have the correct measurements and you are at least 21 years old, have healthy eyes, are free of any medical or eye disorders that may interfere with healing, and have had a stable prescription for a minimum of one year. You should not be pregnant and you should not be breast feeding at or near the time of the procedure.

The technology is extremely precise with each pulse of the laser removing microscopic amounts of tissue (0.25 micron) under computerized control. The unpredictability in laser vision correction occurs because every person and every eye heals differently.

Reference: Dr. Neil Friedman

It's Not Safe Just Because It's an Herb

2008-04-08T23:08:00.000-07:00

If you are thinking about taking a dietary supplement, then this NIH sponsored site is a good place to learn some of the facts about each supplement. It grades the strength of the scientific evidence for each of the reported uses. There is also a good review of the safety profile, dosing and history of each item.

Although herbs and supplements are often touted as being natural, they should be considered to be just another medication. Anything that is ingested and which is absorbed systemically may have side effects or contraindications. In addition dietary supplements do not require FDA approval. In 1994 a law was passed that classified supplements as food. Here is a list of drugs found in some dietary supplements - lovastatin, estrogen, alprazolam, indomethacin, warfarin, and sidenafil (Viagra).

Always inform your doctor about any herbs, supplements, or concoctions that you are taking. That garlic pill that you are taking may increase your risk of bleeding after surgery or dental procedure, and the aristocholic acid in a Chinese herbal weight loss product may cause kidney failure and cancer (Med lett Drugs Ther 2002;44:84).

Fever Is Your Friend

2008-04-01T10:56:00.000-07:00

Dr. Janesta Noland, one of the premiere pediatricians in the bay area, has agreed to share her expertise with us and to answer some of your questions on children's health issues.

Many parents fear that fever represents something dangerous happening in their child’s body. Could the child have a dangerous infection? Could the fever itself cause damage?

First, let’s talk about fever – what it is and what causes it. A fever is defined as temperature of 100.4F (38C) or greater taken rectally, 99.5F (37.5C) taken orally, or 99F (37.2C) taken under the arm. Fever happens when the body’s thermostat increases its set point. (Of note, children may sometimes develop increased body temperature when playing, but this is not fever because the set point is not elevated and the body will respond appropriately to return the temperature to normal.) Body temperature is controlled in the brain in a structure called the hypothalamus. Certain cytokines (cell activators) stimulate the hypothalamus to increase body temperature by increasing heat production via shivering or increased muscle tone and by preventing heat loss via constriction of blood vessels. External factors such as some parts of bacteria also act on the body to trigger fever.

Why does fever happen? Is it a disease? Fever was first identified as a symptom rather than a disease by a German physician in the 1800s. Fever is thought to make the body a more inhospitable place for invading organisms, some of which have strict temperature preferences. Fever also increases the effectiveness of white blood cells at fighting infection: they move more effectively, remove offending organisms more effectively and are less sensitive to toxic effects of invading organisms. Thus, fever may actually be desirable in helping rid the body of infection! Fever can be dangerous at extremely high temperatures, over 107F, but the primary downsides of fever are increased need for fluid and general discomfort. In young children (under 5 years), febrile seizures occasionally occur. Although frightening, these are not dangerous.

How can a parent know when to treat a child’s fever, or when to call a pediatrician? Here are general guidelines:
1) Any fever in an infant less than 8 weeks old should be brought to the attention of your pediatrician immediately.
2) Call your pediatrician if your child acts very ill, is not arousable, has a stiff neck or will not drink.
3) Signs of fever associated with a bacterial infection include stiff neck, pain on urination, or cough together with decreased energy. See your pediatrician if any of these signs occur.
4) Since both bacteria and viruses can cause fever, and since viruses are much more common, it is OK to observe your child if she is well-appearing when her temperature is down and is able to take in liquids. However, if the fever lasts more than 4 or 5 days (at which point most fevers caused by viruses go away), or if fever recurs after going away for a day or two, see your pediatrician to evaluate for a possible secondary bacterial infection.
5) If your child has a febrile seizure, call your pediatrician.

References: please see above links.

Pregnancy, Air Travel, and Radiation Exposure.

2008-03-23T23:46:00.000-07:00

There has been some concern and some misconceptions regarding air travel risk during pregnancy. In general casual air travel is considered not to be an issue in terms of radiation exposure. However, those who travel frequently such as pilots, flight attendants, couriers, and very frequent business travelers are advised to reduce their flight time.

This paper from the American College of Obstetricians and Gynecologists reviews the guidelines in detail. Here's a summary:

~The magnitude of in-flight exposure depends on altitude and on the 11 year solar sunspot cycle. There is less exposure on a short-haul low altitude flight (SF - Seattle) vs a long-haul high altitude flight. Travel bet New York (NY) and Tokyo on transpolar flights approximates at 150 microsievert = 15 mrem whereas between NY and Seattle is 60 microsieverts = 6 mrem.

~Most radiation experts agree that there's no fetal harm such as mental retardation, growth restrictions, or miscarriages at a dose below 20 millisieverts (mSv) = 2 rem. The long term risk, however, in terms of future risks such as leukemias has not been established - neither confirmed nor ruled out.

~Maximum exposure for a woman through her 40 week pregnancy is advised to be 1 mSv = 100 mrem. So the 2 trips described above would give 15% and 6% of the maximum permitted exposure. You would need at least 7 trips of the transcontinental or 17 trips of the intercontinental duration to reach the maximum dose allowed. The actual amount during each flight can be calculated here if you know the altitudes.

~ The FAA gets an advisory about the solar activity and when to avoid routes when the activity is peaking. Real time proton intensity info is available online from Space Environment Center of the National Oceanic and Atmospheric Administration.

In terms of non-radiation risks with air travel, it should be noted that the safest time to travel is considered to be during the second trimester between 18-24 weeks when the risks for miscarriages and preterm delivery are lowest. In an uncomplicated pregnancy, it is advised not to travel after 36 weeks. In a complicated pregnancy the recommendations would be different.

And as always it is best to consult with your doctor if you have any concerns regarding traveling while pregnant.

Do Antioxidants Prevent Cancer?

2008-03-16T22:12:00.000-07:00

It's easy to recommend fruits and vegetables as a source of antioxidants. Observational studies have consistently shown an association between diets high in fruits and vegetables and a lower risk of cancer and heart disease. However, I'm often asked about taking antioxidants as supplements. Pills are easier to take in our time-starved society.

Several studies have been done to determine the role of supplements in reducing the risk of cancer and cardiovascular disease, but the results have been mixed. In a recent paper in the Mayo Clinic Proceedings a systematic review of 12 randomized clinical trials was done to evaluate the effect of antioxidants on cancer incidence and cancer deaths. These trials studied Vitamins C and E, betacarotene, selenium, zinc and lycopene. The majority of the trials included a population of at least 10,000 subjects.

The review concluded that overall there was no reduction in the total number of cancers or in the number of deaths due to cancer. However, in breaking down the data by antioxidants, there were a few antioxidant specific findings. Beta carotene was associated with a slightly higher risk of cancer in smokers. Vitmain E had no effect on cancer incidence or mortality. Selenium was associated with a borderline reduction in cancer incidence and mortality, but this effect was mainly seen in men.

Bottom line is that it may be best to get your antioxidants from food and not from pills.

Photo: courtesy of balanced living.

Anxiety and Heart Attacks

2008-03-11T11:37:00.000-07:00

Many psychological factors such as stress and hostility have been associated with an increased risk of heart attacks. A recent study in the Journal of the American College of Cardiology evaluated whether anxiety independently and prospectively predicts the onset of heart attack (myocardial infarction - MI).

The study included 638 men (mostly Caucasian) with a mean age of 60 who did not have any history of heart disease. Initial evaluations were done with the Minnesota Multiphasic Personality Inventory, a full psychosocial assessment, laboratory data, and full medical exams. The evaluations were repeated every 3 years over a course of 12 years. Other variables such as smoking, lipids, and body mass index were taken into account. By 2004, there were 74 new cases of heart attacks. In univariate analyses, all measures of anxiety predicted future MI with a relative risk of 1.31 to 1.39. Clinically significant anxiety was associated with a relative risk of 2.1 - 2.5. It was concluded that moderate to severe anxiety was associated with a higher risk of heart attacks in this group of older white men.

It should be noted that anxiety is common in our culture and in all age groups. It is one of the most common conditions that I see in my practice. The causes may be situational or biological. There are many ways to cope with and manage anxiety. Here's a free on-line relaxation audio program. There are many other techniques such as progressive muscle relaxation or deep breathing techniques which may be used. If these techniques are not successful then a mental health professional and medications may be helpful. Consult your physician if you have concerns about symptoms of anxiety.

Resources for patients:
National Institute of Mental Health, toll-free information line is 1-866-615-6464.
Anxiety Disorders Association of America. 8730 Georgia Avenue - Suite 600Silver Spring, MD 20910 Telephone: 240-485-1001Fax: 240-485-103

References: see above links.
Photo: courtesy of photo blog graphoria.

What Families Eat Around the World.

2008-03-03T21:52:00.000-08:00

Take a look at these pictures and notice what's lacking in the American family's week of food compared to the other countries. In case you can't spot it because you haven't had enough of it lately - it's produce - fruits and vegetables.

For more details on the gathering of this information and a breakdown of the foods see this NPR interview with the authors of Hungry Planet: What the World Eats.

Travel Vaccines for Costa Rica

2008-03-02T22:37:00.000-08:00

It is best to plan ahead for healthy travel.

The following vaccines are recommended by CDC when traveling to the beautiful country of Costa Rica.

~Tetanus-diphtheria-pertussis (1 shot) if your last one was more than 10 years ago.

~Polio (1 shot) one time only needed as an adult.
~Measles (1 shot) if you have not had the disease or 2 doses of MMR(measles/mumps/rubella) vaccine. A blood test can also be done to see if you have had the vaccine. Please note that measles is a live vaccine and that it should not be given to pregnant women or to those with immunosuppression. Also women are advised not to get pregnant for 4 weeks after receiving the MMR.

~Typhoid (4 pills) which are taken 1 every other day, and will be good for 5 years OR (1 shot) which will be good for 2 years. It should be taken at least 2 weeks before the trip. Note that the pills should be refrigerated, and that this is also a live vaccine.

~Hepatitis A (2 shots) the first dose should be given 4 weeks prior to your trip to be maximally protected. You will need a second shot in 6-18 months to be protected long term.

~Hepatitis B (3 shots) 2 of which are given 4 weeks apart and the third is given in 6 months. You should complete the first 2 shots before departure. This is especially recommended if you might be exposed to blood or body fluids (for example, health-care workers), have sexual contact with the local population, or be exposed through medical treatment.

~ Chloroquine is the recommended antimalarial if you are going to Alajuela, Limón, Guanacaste, and Heredia provinces. No risk in Limón city (Puerto Limón). YES, this is recommended.

~Varicella or chicken pox vaccine (2 shots) if you have not had the disease or the vaccine.

~Rabies, I have not found this to be necessary for most routine travelers. Consider it if you may have extensive unprotected outdoor exposure in rural areas, such as might occur during camping, hiking, or bicycling, or engaging in certain occupational activities.

~Flu shot- the flu occurs year round in tropical regions.

~Ciprofloxacin (an antibiotic) in case of traveler's diarrhea. If diarrhea occurs and is lasting more than 24 hours or is associated with blood or fever then take one tablet of Cipro twice a day for 3 days.

Over the counter medications to consider depending on your needs:

Imodium for diarrhea.

Diphenhydramine(Benadryl) for allergic reactions, motion sickness, nausea, and as sleep aid.

Hydrocortisone for skin reactions.

Sudafed for congestion, especially if before a flight.

Acetominophen(Tylenol), Ibuprofen(Advil) or other anti-inflammatory medication.

DEET containing mosquito repellant.

Misconceptions about immunizations, for you non-believers :)

Photo: courtesy of nikkiartwork.

The Yips

2008-02-19T21:02:00.000-08:00

Dr. Anthony Luke, our blog's sports specialist, has been helping out with some of your sports related questions.

A golfer asks: When the pressure is on I seem to tense up and “choke”. People tell me I have the “yips”. What are these? Please help.

Dr. Luke responds: As you know, putting requires extreme precision. Perfect motor control leads to the perfect putt. Control of movement requires a combination of neural input, proper posture and visual-motor coordination. “Proprioception” allows a person to sense one’s body parts in space which makes balance and complex movements in sports possible. Unfortunately, anxiety can cause one’s sport ability to decrease temporarily. Everyone can get nervous in a pressure packed situation. Practicing one’s sport both physically and mentally can help develop confidence so that even at crunch time the game-winning putt becomes routine. This mental ability to handle stress and perform under pressure is often what makes someone a champion.

The “yips” is something different. “Yips” refer to a dystonia, which is an abnormal involuntary movement that involves the nervous system. This involves an abnormal motor pattern that develops whenever a certain situation occurs. Because of the problematic movement pattern, when you want to do something, your body does something else. This can certainly be a problem if every time you want to putt straight you putt left. In these cases, the brain needs to be retrained to perform the proper movement pattern. Though rare, a dystonia can be extremely difficult to treat and unlearn a bad habit. A neurologist with experience in abnormal movement behaviors may be a great assistance.

Photo: courtesy of jupiterimages.

Pink Eye

2008-02-13T10:52:00.000-08:00

Pink eye is a common infection of the surface skin, or conjunctiva, of the eye. It is similar to a “cold” of the eye, and is known as acute conjunctivitis. Conjunctivitis is just a medical term that means inflammation of the conjunctiva. Many things can cause conjunctivitis, most commonly an allergy or infection. Pink eye is a form of acute conjunctivitis that is usually caused by a virus.

It is very contagious and is spread by direct contact. For example, a person who has pink eye who has rubbed his eyes and used that hand to open a door could end up infecting someone else who touches that door. This is why it is encouraged that people who are diagnosed with pink eye should stay home until the infection has resolved.

Pink eye is associated with characteristic symptoms: redness, swelling, itching, burning, and crusting of the eyelashes when waking up from sleep. There may be discharge from the eye, which is typically clear. A lot of yellow discharge is a sign of bacterial infection. The eye may be watery and sensitive to light.

The degree of symptoms varies from minimal redness and irritation to severe swelling, discharge, and decreased vision. Usually one eye is involved before the other, and within days both are affected. In adults, involvement of only one eye is more common since we tend to avoid spreading it to the other side. The conjunctivitis may be preceded by an upper respiratory infection with fever, congestion, and swollen nodes. Fortunately, the common viral form of pink eye is self-limited, lasting one to two weeks. In some cases, however, small white spots develop on the cornea and may cause decreased vision, which can last for months.

Treatment of viral pink eye is mainly supportive and is aimed at relieving the symptoms. Over-the-counter antihistamine drops such as Naphcon A, Vasocon A, and Opcon, help reduce the itching and redness. Cold compresses reduce the swelling and soothe the eye. Warm compresses in the morning are used to remove the crusting from the lashes. In children, contact lens wearers, and anyone with corneal involvement, an antibiotic drop or ointment should be used to prevent a bacterial superinfection.

If there are signs of a bacterial conjunctivitis, such as colored discharge, severe inflammation, or no improvement with treatment, antibiotics must be used. For borderline cases a culture may be helpful. If corneal opacities are present, your eye doctor may recommend a course of steroid eye drops. Contact lenses must not be worn until the infection is completely resolved. In addition, contact precautions minimize the chance of spreading the infection to the other eye and to other people (ie, hand washing, no eye rubbing, no sharing of face towels or pillow cases, etc.).

Consultant: Dr. Neil Friedman.

The Flu Has Arrived

2008-02-11T23:13:00.000-08:00

The flu virus is now among us. It has arrived late but it has hit hard. A higher than average number of cases has been reported throughout the country. Part of the reason for the increase in this number may be that a new strain of flu virus has emerged during this season.

The vaccine is designed to protect against three influenza strains. According to the CDC, 30 percent of the overall strains of influenza in the United States may be a strain that emerged in Australia called H3N2 A/Brisbane. It emerged too late to be included in the flu vaccine offered in the United States. However, the vaccine may help reduce the complications as well as the severity of the illness if exposed to the new virus. It is still not too late to receive the flu shot.

The flu infects about 20 percent of the population, causes the hospitalization of 200,000 people and kills 36,000 each year. Typical flu symptoms include a high fever of 101 to 103 F (38-39 C), body aches, extreme fatigue, sore throat, congestion and some gastrointestinal issues. The symptoms may last 5-10 days and are much more severe than cold symptoms. See here to assess if you have the flu. Please do not come into work if you have a fever or if you think you have the flu. Stay at home and rest.

Over-the-counter medications, such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) may help make you more comfortable. Children and adolescents should avoid taking aspirin. Decongestants such as pseudophedrine (Sudafed) and antihistamines such as diphenhydramine (Benadryl) or loratidine (Claritin) may help reduce congestion and runny nose.

Flu symptoms usually resolve spontaneously. There should be a general improvement by day 5. You should consult your physician if the symptoms get worse after one week or if any new symptoms such as a severe ear pain, cough, or shortness of breath develop.

References: please see above links.

Folate Reduces Premature Births

2008-02-01T21:43:00.000-08:00

A new study concludes that women who take folic acid (folate) for one year reduce their risk of giving birth to premature babies by 50 to 70 percent. The recommended dose is 400 micrograms per day. Since more than one half of women who become pregnant have not planned their pregnancies, it is recommended that all women of child-bearing age take this supplement.

Stretching Exercises

2008-01-30T20:10:00.000-08:00

Often physicians advise their patients to do stretching exercises but due to time constraints on their schedule, they don't have the time to explain the exercises in detail. Here's a quick tutorial on stretching different muscle groups that may be helpful. This site has been a useful tool for many of my patients who are not familiar with proper stretching techniques.

How to Treat Acne

2008-01-27T21:15:00.000-08:00

Acne is a chronic condition, but almost all cases of acne can be treated. Appropriate management should heal current lesions, prevent new lesions and minimize scarring. It is important to remember that proper treatment of acne takes time, at least 4 to 6 weeks. Fast acting potions are false promises. It is also crucial to be consistent with therapy. Non-compliance is the most common cause of treatment failures.

The type of medication used to treat acne depends on the severity of the condition. Mild to moderate acne is treated with topical medications such as retinoids, benzoyl peroxide, salicylic acid and topical antibiotics. Topical retinoids are the foundation of treatment. They are a derivative of vitamin A and work to unclog pores and prevent whiteheads and blackheads from forming. They may cause an initial irritation of the skin in the first 2-4 weeks. This is a common reaction and can be managed by moisturizing the skin, using sunscreen and increasing the dose of the retinoid gradually. My personal choice is Adapalene (Differin) because it is non-photosensitizing (doesn't cause irritation with sun exposure) and it can be used in the mornings. Other retionids include Treinoin (Retin-A) and Tazarotene (Tazorac) which is reserved for oily skins.

In general, if the topical retinoid alone is not sufficient, then a combination of the retinoid with a topical antibiotic (newly approved Ziana Gel) or a combination of benzoyl peroxide with a topical antibiotic (Duac or Benzaclin) may be given for a broader coverage. I prefer Duac because it does not need to be refrigerated and it can be applied once a day which improves compliance.

Oral agents are used to target moderate to severe acne. These include antibiotics, isotretinoin (Accutane), birth control pills, testosterone blockers and corticosteroids. Antibiotics are the most commonly used of these options. They include tetracycline, doxycycline, minocycline, and erythromycin. Each of these has its own set of side effects. The choice of the antibiotic depends on the tolerance of side effects as well as the cost with doxycycline and tetracycline being the least expensive and minocycline being the most expensive. Antibiotics are generally given for 3-6 months and are then tapered off.

Almost all birth control pills can help reduce acne for the majority of women. They are especially useful for premenstrual flares of acne. My preferred oral contraceptive for acne is Yasmin because it helps to block the affect of androgen on the sebaceous (oil producing) hair follicles. Other pills are Demulen 1/50, Orhto-Tri Cyclen, Orhto-Cyclen, Ortho-Evra, Mircette, Brevicon, and Modicon. All of these are higher estrogen, lower androgen potency pill.

Please note that Depo-Provera, a long acting progesterone contraceptive, is often associated with acne. It needs to be avoided in patients with acne.

Severe acne with scarring may be treated with Accutane. Patients should not get pregnant during treatment with this medication because it can cause birth defects. The treatment is 20 weeks long and the major side effects are dryness of the lips. The patient should also be monitored for depression and for abnormalities in liver or cholesterol by routine blood tests.

Once the acne is controlled, there are several methods available to improve the scarred areas. These include fillers, chemical peels, dermabrasion, or laser resurfacing. These procedures may be done by a dermatologist or a plastic surgeon.

References: please see above links.

Resources: Acne tutorial. NIH Questions and Answers about Acne. AcneNet.

What Causes Acne

2008-01-22T22:04:00.000-08:00

Acne vulgaris (pimples) is a common chronic skin condition that occurs in teens and adults. It results from faulty follicular keratinization - some of the skin cells get sticky and don't exfoliate properly. This causes microcomedones. There is also sebaceous gland hyperactivity which causes an increase level of oil production by the skin. Under these conditions the skin surface bacteria, Propionibacterium acnes, proliferates more heavily which may lead to inflammatory acne. Occasionally these changes may lead to scarring.

Factors that influence acne include:
-Medications such as steroids, Lithium and other mood stabilizers as well as certain contraceptives such as depo-provera.
-Menstrual cycle
-Emotional stress which leads to higher levels of certain hormones such as cortisol and androgens
-Overproduction of androgens
-Family history
-Materials that obstruct the follicles such as helmet straps, shoulder pads, or tight headbands
-Picking

Factors that don't cause acne are:
-Chocolates, fatty food or sodas
-Poor hygiene
-Not washing the skin vigorously

You don't just grow out of this condition. There are treatments which work for acne. These will be covered in the next blog.

What's the Skinny on Diet Pills

2008-01-17T23:16:00.000-08:00

I don't advocate diet pills. There are no short cuts to long-term weight loss. However, a frequently asked question, especially during this time of the year, is what's new with diet pills.

A few years ago, the combination of phenteremine ad pondimin,( phen-fen), was quite popular. Both medications were effective appetite suppressants and they helped patients lose weight faster. However, their use was discontinued when they were associated with valvular heart disease.

Current medications which are available include orlistat (Xenical, Alli) and sibutramine (Meridia). Orlistat interferes with absorption of fats by interfering with one of the digestive enzymes in the intestines. Diarrhea, gas, and dyspepsia are the most common side effects. It results in 3 kg. (6.6 lbs.) more weight loss than placebo after 1 year.

Sibutramine suppresses appetite by working on the appetite control centers of the brain. It affects the processing of certain brain hormones such as serotonin. It was shown to result in 4.5 kg (9 lbs.) more weight loss than placebo in 1 year. The side effects include dry mouth, insomnia, and nausea.

There are several other medications which are currently under investigation but which have not yet been approved in the United States. Many of these work by by decreasing the activity of the endocannainoid system (EC). This is the same brain circuit that makes people hungry when they smoke cannabis (marijuana).

The EC system is a recently recognised physiological system that includes receptors such as the CB1 receptor and and which has been shown to play an important role in regulating body weight and in controlling energy balance. Rimonabant (also known as Zimulti, Acomplia or Slimona) has already been approved in Europe. It works by blocking the CB1 cannabinoid receptor. In one study it stopped food craving and helped overweight people lose an average of 20 pounds. It also was found to decrease craving for certain addictive substances. The side effects associated with this medication have been depression and anxiety.

While these medications may have a role in short term treatment of obesity, they are not recommended for long term weight management. Each medication has its own profile of side effects. Exercise and proper nutrition remain the safest regimen although admittedly not the most immediately gratifying solution.

References: Drugs Fut 2007, 32(9): 766
Photo: courtesy of La Verne Magazine

Life Expectancy

2008-01-15T20:29:00.000-08:00

Life expectancy at birth reached a record high of 78 years in 2005 for the U.S. population. The United States ranks 45 in the world in life expectancy. See here for a ranking of the other countries.

Reference: National Center for Health Statistics

Changes in Urine Color

2008-01-13T22:08:00.000-08:00

A patient came in today panicked because his urine had turned red. This is a frightening experience for most patients, and of course the doctor should be consulted for this condition. There are several medical conditions which may cause changes in the color of urine ranging from red to orange to brown. However, there are also some benign causes such as the types of food that have been consumed, as well as any food colorings, over-the-counter or prescription medications, or diagnostic dyes that were recently ingested.

Althought this is probably more detail than you would ever want to know about your urine, here is a very complete review by Dr. Martha Terris of the possible causes of different urine colors.

The normal color of urine ranges from light yellow to dark amber, depending on the concentration of solutes in the urine. The more dehydrated that the body is the darker yellow the color of the urine may look. Urochrome is the name of the pigment that gives urine its characteristic yellow color. Other urinary complaints may accompany changes in urine color. Such symptoms include urinary urgency (having to hurry to get to the bathroom), frequent urination, burning pain with urination (indicative of infection), or colicky pains (suggesting kidney stones).

Pink or red urine should prompt an immediate visit to your doctor. The first test is a dipstick for blood. A positive dipstick for blood implies the presence of red cells, free hemoglobin (from broken down red blood cells), or myoglobin (from broken down muscle cells).

Red blood cells in the urine may be from kidney loss (termed "glomerular" blood cells) in patients with renal disease. Red cells in the urine of these individuals will usually be misshapen and accompanied by protein in the urine. Normal appearing red blood cells (termed "epithelial" red blood cells to identify them as cells coming from the lining of the urinary tract instead of the kidney) may be present during a urinary tract infection, urinary stone, or urinary malignancy. Red blood cells are common in the urine after urologic procedures and occasionally following catheter placement. Complete urine testing (called "urinalysis") for the presence of bacteria and white blood cells, urine culture, cystoscopy, CT scan, and/or other imaging studies may be necessary to clarify the source of the blood.

If the urine is red and acid but does not contain hemoglobin, myoglobin, or red blood cells, suspect an indicator dye such as phenolphthalein (the laxative in ExLax) in which case the red should disappear when the urine is alkalinized with a few drops of potassium hydroxide. Blackberries and beets can turn acid urine red due to the presence of anthrocyanin, while rhubarb, anthraquinone laxatives, and some diagnostic dyes will redden urine only when it is alkaline. The anesthetic, propofol, has been reported to cause pink coloration of the urine, particularly in alcoholics. Other medications that can cause red urine are the phenytoin, phenothiazines, e.g., Compazine. Red urine can also be caused by chronic lead and mercury poisoning.

Orange urine may be produced by phenazopyridine (Pyridium) or ethoxazene (Serenium), both of which are used as urinary tract anesthetics to diminish urinary discomfort. Rifampin, phenacetin, sulfasalazine, Vitamin C, riboflavin, and carrots will also turn urine dark yellow to orange. An opaque orange-pink urine color can result from abundant uric acid crystals which can be seen in acidic urine of patients who have undergone intestinal by-pass surgery or are receiving chemotherapy for malignancy.

Blue or green urine may be caused by a blue dye such as methylene blue, a component in several medications (Trac Tabs, Urised, Uroblue) used to reduce symptoms of bladder inflammation or irritation. Administration of the dye, indigo carmine, turns the urine green and can last for several days if renal function is poor. While more often reported to cause pink urine, the anesthetic, propofol, has also been reported to cause green coloration of the urine. Amitriptyline, indomethacin, resorcinol, triamterine, cimetidine, phenergan, and several multivitamins also lend a blue-green tint to the urine. An inherited form of high calcium (called "familial hypercalcemia") can result in blue urine, which has lent this disease the nickname "blue diaper syndrome". Another metabolic disorder, indicanuria, can cause blue urine due to tryptophan indole metabolites. A blue pigment may also be produced by infection with the bacteria Pseudomonas . Dark green pigmentation, especially if associated with air (known as "pneumaturia"), urinary tract infection, and/or solid particles in the urine, can be caused by bile when there is a fistula between the urinary tract and the intestines.

Brown or black urine (not due to myoglobin or bilirubin) may be caused by excessive L-dopa or melanin excretion as well as copper or phenol poisoning. Ingestion of large amounts of rhubarb, fava beans, or aloe can cause dark brownish black urine. Metabolites of the antihypertensive medication methyldopa (Aldomet) may turn black on contact with bleach (which is often present in toilet bowls) . Other medications causing brown or brown-black urine are chloraquine and primaquine, furazolidone, metronidazole, nitrofurantoin, cascara/senna laxatives, methocarbamol, and sorbitol. Contamination with povidone-iodine (Betadine) solution or douche can turn urine brown. Melanin and melanogen, found in the urine of patients with melanoma, will darken standing urine from the air-exposed surface downward. Alcaptonia, a rare hereditary disease, will turn the urine dark after being exposed to the air over a period of time due to the presence of homogentisic acid. Urinary hydroxyphenylpyruvic acid excretion due the metabolic disorder tyrosinosis will also cause urine to be brown-black in color. In porphyria cutanea tarda, the urine will appear reddish brown in natural light but fluoresces pink under ultraviolet light.

White or cloudy urine is most commonly a result of phosphaturia. This is a benign condition in which excess phosphate crystals form in urine. Adding a drop of acetic acid to the urine sample will result in immediate clearing of the urine. Phosphaturia is usually intermittent, occurring following a meal or after ingesting a large quantity of milk. White urine is sometimes due to pyuria (abundant white blood cells) in association with an infection of the urinary tract. White cloudy urine can rarely be due to chyluria (lymph fluid), resulting from a communication between the lymphatic system and the urinary tract.

Please contact your physician with any concerns that you may have.

Reference: Dr. Martha Terris.
Photo: courtesy of News Target

Asthma Control Test

2008-01-10T14:47:00.000-08:00

If you have asthma, take this test and share the results with your doctor.
The Asthma Control Test (ACT) is designed to give you an idea of how well your asthma has been controlled over the last 4 weeks. It can also help your doctor determine how well the treatment plan is working for you.

The test is for ages 12 and older. It consists of 5 simple questions which are scored individually. The maximum score is 25. If your score is less than 20, it means that your asthma is not well controlled. The test can be taken at any time. and since asthma symptoms may vary it may be worthwhile to use this test at regular intervals or if you sense a change in your condition.

The National Heart, Lung, and Blood Institute recently recognized ACT as a validated instrument for the assessment and monitoring of asthma in its Guidelines for the Diagnosis and Management of Asthma.

Fish Oils May Prevent Alzheimer's Disease

2008-01-06T20:57:00.000-08:00

A recent study from the University of California Los Angeles Departments of Medicine and Neurology concludes that fish oils may help prevent Alzheimer's disease. The researchers found that omega-3 fatty acid docosahexaenoic acid (DHA), which is found in fish oil, raises the production of LR11, a protein which destroys the plaques in the brain which have been associated with Alzheimer's disease.

These plaques which are toxic to the brain cells are deposits of a protein called beta-amyloid.
Patients with late-onset Alzheimer's disease tend to have a high number of these plaques and very low levels of LR11. Both genetic and environmental factors may contribute to this process.

The scientists administered the fatty acid by diet to mice and also directly to cultured human neuronal cells to evaluate its effects. They found that even low doses of DHA increased the level of LR11 in the brain cells. "Consequently, elevated levels of DHA, which in turn lead to an abundance of LR11 appear to protect against Alzheimer's disease, while low LR11 levels have the opposite effect as they allow the formation of the amyloid plaques."

DHA is considered an "essential" fatty acid because it can only be obtained through diet. Our bodies cannot produce it from any other source. It is also the most abundant essential fatty acid in the brain and has been known to be important for healthy brain development in the fetus.

Other benefits of omega-3 fatty acids include lowering cholesterol and triglyceride levels, cardiovascular protection, and anti-inflammatory and anti-blood clotting actions. They have also been reported to help reduce the risks and symptoms for other disorders such as rheumatoid arthritis, asthma, psoriasis, eczema, inflammatory bowel disease, ulcerative colitis, and depression.

As a result of these findings, the National Institute of Health is currently carrying out a large-scale clinical trial with DHA in patients with established Alzheimer's disease. Further studies are needed to confirm these findings and to establish a dose that may be helpful in the prevention of the disease.

References: please see above links.
Photo: courtesy of Pharma Gazette.

Hold On to Your Resolutions

2008-01-01T21:52:00.000-08:00

Here's a quick tip to help you to stick to your resolutions. Whether you have resolved to lose weight, to exercise, or to quit smoking, 90 percent of people give up on these resolutions in 2 to 3 weeks. However, it takes at least 30 days to begin to change a bad habit into a positive routine. So what ever goal you are setting, commit to it for the next 30 days. Instead of saying you want to exercise more this year, you may want to say that you will exercise more for the next 30 days. Hopefully after that period of time, the next 30 days will be easier, and so on and so on.

Holiday Blues

2007-12-23T14:04:00.000-08:00

"Merry Christmas" and "Happy Holidays" sometimes don't make you feel so merry and happy. Holiday blues - feeling sad and lonely - is common during this time of year. The causes are many and include unrealistic expectations, memories of past holidays, having to deal with family or inability to be with family, stress, finances, and fatigue. Often these symptoms are short-lived, but they can be intense.

Some helpful do's and don'ts from University of Maryland Medical Center are:
Do give yourself a break - everything doesn't have to be a Hallmark moment. It's OK if the meals aren't perfect or you haven't found time to decorate the house. Do let go of the past and create new ways to celebrate. Do spend time with people who care about you. Organize your time and set realistic expectations. Find someone to talk to, a friend, family member, doctor or counselor.

Photo: courtesy of inspiration line.

Canker Sores

2007-12-12T23:44:00.000-08:00

Canker sores or aphthous ulcers are small, painful, shallow ulcerations that occur on the soft tissues inside the mouth. Stress or tissue injury is believed to contribute to the development of canker sores, although the actual cause is unknown. Other possible factors include immune system dysfunction, vitamin deficiencies such as B-12, zinc, folic acid or iron, disease of the gastrointestinal tract, food allergies, or hormonal changes such as menstrual periods. There can also be a hereditary predisposition to developing these sores. They are not contagious and normally resolve without any intervention in 10-14 days.

Occasionally these sores can be recurrent or large and complex. For these cases there are several treatment options. Dr. Nasim Fazel makes the following recommendations.

Topical therapy - Steroid compounds such as flucinonide (Lidex) or clobetasol gel for lesions which are easily within reach or dexamethasone (Decadron) elixir (0.5 mg/5ml) to swish around in the mouth for lesions that are in the back of the throat.
Systemic therapy - Several immune system modifying medications may be used for the more severe cases. These include prednisone either in a short term therapy of 40-80 mg every day for 4-5 days or a long term dosing regimen with gradual taper; pentoxifylline (Trental) 400 mg three times a day for at least 3-6 months and usually for 1 year; colchicine 0.6 mg 2 to 3 times a day, dapsone 100-200 mg daily or azathioprine (Imuran) 50 mg twice daily for 2 weeks. Each of these medications has its own set of side effects which should be weighed against the benefits.
Pain control therapy - Zilactin which is an over the counter gel, sucralfate(Carafate) to provide a protective coating over the ulcer, or viscous lidocaine 2% to be taken about 20 minutes before meals to reduce the discomfort while eating.

What ever option you chose, please don't do this.

Photo: courtesy of kidshealth.

Primary Care Physicians - Quarterbacks of Your Health Care

2007-12-04T22:31:00.000-08:00

I have learned never to assume anything in medicine. This is particularly true in coordinating my patients' care when more than one doctor is involved. Communication is essential for a successful outcome in medicine. This has become increasingly difficult in the health field for multiple reasons. Patients do not establish with a primary care doctor or they change doctors frequently, multiple facilities or specialists may be involved, and overburdened and overworked physicians lack the time needed to follow through on consultations as ideally as possible. The following case unfortunately demonstrates the poor outcomes which may occur as a result of a lack of communication.

A 37 year old man presented to the emergency room (ER) with a severe headache. He was examined by the ER physician (provider#1) who ordered a CT scan of the brain. The scan was reviewed by the radiologist (provider #2) who saw evidence of a blood clot but thought that it was an old injury. He did not contact the ER doctor with this information. The ER doctor then transferred the care of the patient to the new ER doctor (provider #3) at the end of his shift. He did not follow up with provider #2 regarding the results of the scan. The new ER doctor (provider #3) determined that the patient needed cardiac catheterization and transferred the patient to the cardiologist (provider #4). The cardiologist administered a blood thinner to the patient in preparation for a stent placement. The procedure was then performed by another cardiologist (provider #5). After the procedure the patient complained of a severe headache. At this point provider #5 reviewed the chart and found the radiology report which showed the old blood clot. The patient died of brain hemorrhage after the administration of the blood thinner.
Multiple failures of communication compromised this patient's safety.

To optimize your medical care, establish with a primary care doctor if you have not already done so. If you think that you have a good primary care doctor who is responsive and conscientious then stay with them when possible. A long-term relationship goes a long way to establish your doctor as your advocate. Keep your doctor informed if you seek medical care outside of his or her office. The medical system is a confusing one, and it becomes even more complex when you enter it during a crisis. Ideally a doctor who knows you will be in your corner and will help guide you through the maze by communicating and coordinating your needs with all who may be involved in your care.

reference: case from Norcal.

Get Your Sleep

2007-12-03T09:16:00.000-08:00

Hope you've had a good night sleep and that you haven't been staying up late surfing on the internet or emailing. On average most adults need 7-8 hours of sleep. According to a recent study from London those of us who got too little or too much sleep are at a higher risk of death due to both cardiovascular and non-cardiovascular causes.

In this study, 10,000 participants between the ages of 30-55 were evaluated initially between 1985-1988 and again during 1992-1993. Those who had cut their sleeping from 7 hours to 5 hours or less faced a 1.7 fold increased risk in mortality from all causes, and twice the increased risk of death from cardiovascular causes. Those who slept more than 8 hours also had a higher risk of mortality from general causes but not from cardiovascular causes.

Resources: Sleepeducation.com. National Sleep Foundation.

Photo: courtesy of University of Vermont.

Macular Degeneration

2007-11-28T21:34:00.000-08:00

Age-related macular degeneration (AMD) is the leading cause of blindness in the United States among people over 65 years old. Damage to the central retina (macula) and underlying tissue causes loss of central vision. People with macular degeneration often fear that they will lose all vision and be completely blind. This does not happen. Most people continue to have useful vision because the peripheral or side vision is not affected.

Macular degeneration occurs in older people as part of the aging process. Other risk factors include a family history of AMD, smoking, farsightedness, light iris color, high blood pressure, and cardiovascular disease. There are two types of macular degeneration. The more common dry form is due to atrophy of the tissue in the macula, and causes gradual loss of vision. The rarer wet or exudative form refers to abnormal blood vessel growth, or neovascularization, under the macula. These new vessels are fragile and can leak fluid or blood into the macula causing a sudden, profound loss of vision.

The degree of visual changes can range from mild to severe. People with AMD experience different symptoms, and even in the same person, each eye can be affected differently. Initially the central vision becomes distorted and blurry, making close work like reading more difficult. Straight lines may look bent or wavy, and small blind spots may appear. In the late stages, the center of vision may be completely dark or missing.

An examination of the retina to inspect the macula is necessary to make the diagnosis of macular degeneration. The disease can often be detected before the vision is affected. Therefore, it’s a good idea to have routine eye exams to screen for this and other conditions that occur with aging, especially if there is a strong history in your family.

Once macular degeneration is diagnosed, observation with periodic retinal exams and self-testing by looking at a grid pattern (Amsler grid) are recommended. Nutritional supplements may be beneficial for individuals who already have mild degrees of dry AMD. Low vision devices such as magnifiers, special computers, and large-print books, aid in daily activities and help improve visual functioning.

There are also a number of new treatments for the wet form of macular degeneration depending upon the size and location of the abnormal blood vessels. Therefore, any sudden change in central vision should be promptly evaluated. Special pictures of the macula help identify the neovascularization, and the leaking vessels may be sealed with medication or laser. Macular degeneration cannot be cured, but treatment often slows the rate of visual loss. New treatments are being investigated, and there is hope that one day we will be able to cure this disease.

Posted by Dr. Neil Friedman.

Watch a PBS episode on AMD.

Resources: AMD.org

Photo courtesy of Duke Medicine.

Breast Feeding And Smarter Babies

2007-11-24T22:46:00.000-08:00

A new study concludes that breast feeding may help increase IQ in the setting of the right genes. The study followed 3000 children who were fed by breast milk and by bottled formula. Nine out of ten children scored higher by 7 points on the IQ scale if they were breast fed. Breast milk contains fatty acids that help the growth of brain cells. Ninety percent of babies carry the gene variant (C version of FADS2 ) which helps the process by which these fats stimulate brain development. The children who carried this gene and who were breast fed were the ones who scored higher on the IQ test.

One group of the children was born in New Zealand between 1972-73. These children were tested at ages 7, 9, 11, and 13. Fifty seven percent of these children were breast fed. The other group of children was born in England between 1994-1995, and 48% of these children were breast fed. They were tested at age 5. Both groups were tested with Wechsler.

The results were the same for babies with normal or low birth weight. There was not a difference noted in those who were born into a high or low-social-class, or in those who had mothers with high or low-IQs. Children with the FADS2 ‘C’ genotype were no more likely to have been breastfed than children with the FADS2 ‘G’ genotype.

This data helps support the interactive roles that both genetic and environmental factors play in our development.

References: please see links.

Photo: courtesy of msnbc.

Genetic Screening For Breast and Ovarian Cancer

2007-11-23T23:32:00.000-08:00

Mutations in BRCA1 and BRCA2 genes are the most common causes of genetic predisposition to breast and ovarian cancer. A screening test is available , but who should be tested and what can be done if you test positive?

The US Preventive Services Task Force recommends BRCA testing for women in the following groups.

For Ashkenazis, a woman who has:

Any first degree relative (siblings, parents, daughters/sons) with breast or ovarian cancer
Two second degree relatives (grandparents, grandchildren, aunts/uncles, nieces/nephews, half-siblings) with breast or ovarian cancer

For Non-Ashkenazi, a woman who has:

Two first degree relatives with breast cancer
Three or more first- or second- degree relatives with breast cancer
Both breast cancer and ovarian cancer among first- and second- degree relatives
A first degree relative with bilateral breast cancer
Two or more first- or second- degree relatives with ovarian cancer
A male relative with breast cancer

Women with no family history of either breast or ovarian cancer are not recommended to be tested.

If BRCA1 mutation is detected, there is a 57% chance of developing breast cancer and a 40% chance of developing ovarian cancer before the age of 70. If BRCA2 mutation is detected, then there is a 49% and 18% chance of developing the respective malignancies.

According to the American Cancer Society guidelines, women who test positive for BRCA mutation should consider breast and gynecological exams every 6 months. Annual MRI of breasts which have a sensitivity of 75% for detection of breast cancer are recommended starting at age 30. A mammogram is not recommended before age 35 due to concern that ionizing radiation may induce malignant changes in BRCA carriers. The combination of MRI, mammogram, and breast ultrasound increases the sensitivity of detection to 95%.

Although it may be a difficult decision, surgical options should be considered for more definitive cancer risk reduction. A bilateral mastectomy (breast removal) reduces the risk of breast cancer by 90%. A bilateral salpingo-oopherectomy (ovary and tube removal ) reduces the risk of ovarian cancer by 80% and breast cancer is reduced by 50%.

References: The Medical Letter, Vol 49, Issue 1274, November 19, 2007. Also see above links.

Thanksgiving Notes

2007-11-21T17:53:00.001-08:00

Happy Thanksgiving.

Website for Cancer Information

2007-11-18T21:08:00.000-08:00

If you're looking for information on cancer treatment and prevention, here's a site that may be helpful. People Living With Cancer is a doctor-reviewed website provided by the American Society of Clinical Oncology . The website was launched about five years ago to provide accurate data on the treatment and care of several types of cancer, but more recently, it has added a prevention section which the general public as well as cancer survivors may find useful.

Knee Injury In Female Athletes

2007-11-13T20:27:00.001-08:00

Dr. Anthony Luke, Director of UCSF Primary Care Sports Medicine, has been kind enough to share some of his expertise with us. He has agreed to join us for regular blogs on common sports related medical questions with a focus on prevention of injuries.

Do women get more knee injuries?

Unfortunately, women have higher rates of injury to the anterior cruciate ligament (ACL) in the knee. As early as the 1990’s, higher rates of injuries to the ACL in women versus men have been observed (6:1 in basketball and 2:1 in soccer). Researchers have speculated that the greater risk to women is due to various factors, since many reasons can lead to tearing the ligament when an athlete lands with an awkward twisting motion.

The leading reasons include hormonal causes, anatomical variations between men and women, and differences in neuromuscular control. Estrogen hormone receptors have been found on the surface of the ACL and researchers have tried to demonstrate whether the menstrual cycle can affect the laxity of one’s ligaments. So far, an effect has not been clearly shown. The differences in lower extremity alignment is another major area that has been suspected to play a role, particularly the greater angles at the knees due to the wider female pelvis compared to men as well as a smaller notch in the center of the knee where the ligament attaches. Again, no major significance has been noted so far. The most promising explanation for more common ACL tears in females seems to involve the athlete’s ability to balance (proprioception) and control the knee with one’s muscles (neuromuscular control). Because of anatomical and muscle strength differences between average men and women, females have less stability and upper body control which can lead to an awkward fall.

Careful work on co-ordination, balance and hamstring strength can help reduce one’s risk of an ACL tear especially for female athletes. Many professional, college and competitive high school athletes are participating in programs to prevent a season ending knee injury. Activities designed to restore both functional stability about the joint and enhance motor control skills can help prevent injury. Use of balance equipment such as wobble board and jumping exercises on one leg can improve dynamic stability.

In one study, female soccer players, ages 14 to 18, who underwent a neuromuscular training program (Preventative Injury and Enhancement Program (PEP) program) consisting of basic warm-up activities, stretching techniques for the trunk and lower extremity, strengthening exercises, plyometric activities and soccer-specific agility drills had 88% less ACL injuries in the first year and 74% less injuries in the second year. Referring the patient to a health professional familiar with similar proprioception programs may be the best measure to teach the athlete proactively reduce the chance of an ACL tear.

Anthony Luke MD, MPH Director, UCSF Primary Care Sports Medicine 1701 Divisadero St. #240 San Francisco, CA, 94115 415-353-7566

References

Bahr, R., Lian, O. (1997) A two-fold reduction in the incidence of acute ankle sprains
in volleyball.

Caraffa, A., Cerulli, G., Projetti, M., Aisa, G., Rizzo, A. (1996) Prevention of anterior cruciate ligament injuries in soccer.

Dick RW, Arendt E. Gender specific knee injury patterns in collegiate basketball and soccer
athletes.

Emery , C.A., Cassidy, J.D., Klassen, T.P., Rosychuk, R.J., Rowe, B.H. (2005) Effectiveness of a home-based balance-training program in reducing sports-related injuries among healthy adolescents: a cluster randomized controlled trial.

Hewett, T.E., Myer, G.D., Ford, K.R., Heidt, R.S. Jr, Colosimo, A.J., McLean, S.G., van den Bogert, A.J., Paterno, M.V., Succop, P. (2005) Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study.

Mandelbaum, B.R., Silvers, H.J., Watanabe, D.S., Knarr, J.F., Thomas, S.D., Griffin, L.Y., Kirkendall, D.T., Garrett, W. Jr. (2005) Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2 year follow up. Am J Sport Med 33, 1003-1011.

Myklebust, G., Engebretsen, L., Braekken, I.H., Skulberg, A., Olsen, O.E., Bahr, R. (2003) Prevention of ACL injuries in female handball players: a prospective intervention study over 3 seasons. Clin J Sports Med. 13, 71-78.

Blood in the Eye

2007-11-11T10:40:00.000-08:00

Subconjunctival hemorrhage is a common eye condition that brings many patients into my office in a panic. Although it can look impressive and a bit scary, it is a benign condition that resolves spontaneously in 1-2 weeks. It occurs as a result of a breakage of a small blood vessel under the conjunctiva.

It is often caused by minor trauma such as rubbing the eye, sneezing, coughing or straining. It can occur spontaneously if a person is using aspirin or other medications which interfere with blood clotting mechanisms. The condition should be painless and should not cause any vision change. It is best to avoid wearing contact lenses during this time.

It is important to contact your doctor if the blood occurs in the setting of a major trauma or if the blood appears to surround the iris 360 degrees. This could indicate a penetrating injury and should be evaluated fully.

Image courtesy of: Columbia University Eye Institute.

Top Ten Recommendations for Reducing Cancer Risk

2007-11-07T22:40:00.000-08:00

The World Cancer Research Fund (WRFC) recently published their recommendations for reducing cancer risk. The report is based on a comprehensive review of 7000 studies which were conducted worldwide since the 1960's. It is an update from the 1997 report initially published by WFRC and the American Institute for Cancer Research.

The report links weight, exercise, diet, and cancer risk. It concludes that body fat level is closely associated with the risk of developing cancer. Apparently putting on weight can increase cancer risk even if you are still within the healthy range. The closer you are to the lower end of your ideal weight range the lower is your risk of developing cancer. There are no magic elixirs, not even supplements that were proven to be useful for preventing cancer. The good news, however, is that you do have control over many of the factors that contribute to the risk of cancer.

The panel's recommendations based on the extensive review of the literature are the following:
1. Be as lean as possible without becoming underweight. (Ideal weight calculator).
2. Be physically active for at least 30 minutes every day.
3. Avoid sugary drinks. Limit consumption of energy-dense foods (particularly processed foods high in added sugar, or low in fibre, or high in fat).
4. Eat more of a variety of vegetables, fruits, whole grains and pulses such as beans.
5. Limit consumption of red meats (such as beef, pork and lamb) to 750 grams a week, and avoid processed meats.
6. If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a day.
7. Limit consumption of salty foods and food processed with salt (sodium).
8. Don’t use supplements to protect against cancer.
9. It's best for mothers to breastfeed exclusively for up to 6 months and then add other liquids and foods.
10. After treatment, cancer survivors should follow the recommendations for cancer prevention. 10. Don't smoke or chew tobacco.

Here's an interview with one of the authors of the report.

More on Medical Myth Busting

2007-11-07T11:28:00.000-08:00

Here's another great medical myth buster site courtesy of our Canadian colleagues.

Thanks to WellnessAid for sending it.

Busting Medical Misinformation

2007-11-05T19:10:00.000-08:00

A resource that I like to use for debunking medical myths and weird stuff on the net is Quackwatch. The site was created by Dr. Stephen Barrett in 1996, and it has won several awards since then including being named by the Journal of American Medical Association in 1998 as one of the select sites that provides reliable health information. It is a nonprofit organization that aims to "combat health-related frauds, myths, fads, fallacies, and misconduct." My only criticism of the site is that it needs to be better organized. For a quick check, you can click on the "What's New" section.

Misconceptions About Immunizations

2007-11-03T09:32:00.000-07:00

After many years of practicing medicine, there's not a lot that I hear in my office that surprises me. However, recently I met a patient who said that he had not received any of his vaccinations, not even the childhood ones. He was not from a remote corner of the world - he was from Santa Cruz California. It turns out his parents didn't believe in vaccines, and apparently this fear of vaccination is more common than I had realized.

Here are some clarifications of common misconceptions courtesy of Dr. Stephen Barrett which hopefully will help encourage proper health care for everyone. After all, even though many of you may be too young to remember it, where would we be without the polio vaccine.

Misconception #1: Because of better hygiene and sanitation, diseases had already begun to disappear before vaccines were introduced.
Misconception #2: The majority of people who get the disease have been immunized.
Misconception #3: There are hot lots of vaccine that have been associated with more adverse events and deaths than others. Parents should find the numbers of these lots and not allow their children to receive vaccines from them.
Misconception #4: Vaccines cause many harmful side effects, and even death—and may cause long-term effects we don't even know about.
Misconception #5: DTP vaccine causes sudden infant death syndrome (SIDS).
Misconception #6: Vaccine-preventable diseases have been virtually eliminated from the United States, so there is no need for my child to be vaccinated.
Misconception #7: Giving a child more than one vaccine at a time increases the risk of harmful side effects and can overload the immune system.
Misconception #8: There is no good reason to immunize against chickenpox (varicella) because it is a harmless disease.
Misconception #9: Vaccines cause autism.
Misconception #10: Hepatitis B vaccine causes chronic health problems, including multiple sclerosis.
Misconception #11: Thimerosal causes autism: Chelation therapy can cure it.

And while we're clearing up misconceptions, it should be noted that the flu "shot" does not cause the flu. The flu vaccine in the form of the nasal spray however is a live vaccine and may cause a mild case of runny nose and congestion.

Happy Halloween.

2007-10-31T17:07:00.000-07:00

Please don't over do it on the candy.

Image courtesy of: healthline.

When Is the Best Time To Get Pregnant?

2007-10-30T23:57:00.000-07:00

I am often asked about how to predict the best time to attempt pregnancy each month. In general the most fertile time for a woman is 14 days before her next menstrual cycle. If the cycle lasts 28 days, counting the first day of bleeding as day 1, then day 14 is when she should be ovulating. If the cycle is 30 days then it would be 30 minus 14 which would be day 16 of the cycle. This ovulation calculator may be helpful.

For a more accurate prediction there are several kits available over the counter which help eliminate some of the guess work. These may be especially helpful for women who have irregular cycles and who cannot reliably predict their peak ovulation time just by counting days. A few kits that are recommended are Clearblue, Ovuquik, and First Response. Clearblue ranges from $20 to $30 for 7 - 10 test sticks in each box.

These kits work by detecting an increase in the level of luteinizing hormone (LH) in the urine. The hormone is produced by the pituitary gland in the brain. Normally luteinizing hormone level peaks 24-36 hours before ovulation - the release of the egg from the ovary. It is then excreted via the urinary system where it is detected by the monitor stick which is included in the kits.

It is recommended to start testing 3-4 days before the expected day of ovulation. The best time of day to check is in late afternoon - 2 pm and later or at least no earlier than the second morning urine. It is best to avoid the first morning urine because LH can accumulate overnight and show a higher level in that sample. Once the meter reads as positive then the LH surge has occurred. The best time for intercourse then would be on the same day or 12-24 hours later.

If you are not using the kit, then it is recommended to have intercourse every other day starting 4-5 days before the expected time of ovulation. Other tips to help facilitate pregnancy is to avoid using any sperm toxic lubricants. Vegetable oil or Pre-Seed vaginal moisturizer is OK to use. After intercourse lay on your back with knees up for 20 minutes. And if you don't achieve the desired outcome then just try again.

Disclosures: I have no financial interest in any of the companies mentioned.

Which Days Are Good To Test With Fertility Kits

2007-10-29T23:33:00.000-07:00

Here's a quick guide as to when to start testing with the kit. If the cycles are variable then use the shortest cycle period in the last 6 months.

If Cycle Length then Start Testing Day
If 21 days, then start testing at day 5
22 ---5
23 ---6
24 ---7
25 ---8
26 ---9
27 ---10
28 ---11
29 ---12
30 ---13
31 ---14
32 ---15
33 ---16
34 ---17
35 ---18
36 ---19
37 ---20
38 ---21
39 ---22
40 ---23
41 ---24
42 ---25

How Long Does It Take to Get Pregnant?

2007-10-28T20:34:00.000-07:00

Pregnancy rates with "normal" fertility should be expected to be:
-1 month 25%
-6 months 60%
-9 months 75%
-12 months 85%
-18 months 90%

Infertility occurs in 15% of reproductive age couples. It is defined as no pregnancy in 12 months of unprotected intercourse. However, infertility evaluation may be started sooner depending on the woman's age.

In general if there is no history or risk factors for infertility the recommendations for starting infertility evaluation are:
- women under 35 years old to start at 12 months
- women 35-39 to start at 6 months
- women over 40 to start at 3 months

Image courtesy of midcoast abstract gallery.

What's MRSA And What Can Be Done About It?

2007-10-24T08:10:00.000-07:00

I have received many questions regarding MRSA. There has been an increasing number of reports in the press lately about the potential dangers of this particular infection which has been labeled as an epidemic.

MRSA stands for methicillin-resistant Staphylococcus aureus bacteria. It is only one of the superbugs that have emerged over the last several years. Methicillin is a penicillin type antibiotic. Decades ago, a strain of staph (staphylococcus) that was resistant to the more powerful antibiotics emerged in hospitals and was dubbed MRSA.

In 1990's a strain of MRSA was detected in the wider community which was distinct from the clones found in the hospitals. This is now called community-acquired MRSA (CA-MRSA) as opposed to the hospital-acquired MRSA (HA-MRSA). Prevalence and incidence of CA-MRSA has been increasing. USA300 is the predominant clone of MRSA and may be more transmissible. It is the major source of this infection in US, Europe, and Canada, and reports suggest that it has increased virulence.

Staph bacteria are normally found on the skin or in the nose of about one-third of the population. These people who are colonized by staph or MRSA can pass the bacteria to others through direct contact. If the bacteria enter the body through a cut or other broken skin then they can cause more serious illnesses in some people. The infection generally starts as small red bumps that look like pimples or spider bites. These can then quickly become deep painful abscesses. Occasionally they may also go beyond the skin and soft tissues, invading ear, lung, bloodstream, joints, and heart valves.

The infection can be diagnosed by obtaining a culture of the wound. This is an important step because certain antibiotics which are normally used for non-MRSA skin infections such as cephelasporins (keflex) but which are the wrong antibiotics for MRSA may actually turn on the virulence factor and worsen the outcome of the MRSA infection. According to the New England Journal of Medicine 57% of MRSA infections were treated with the wrong antibiotics.

Once diagnosed, a simple incision and drainage of the lesion may be all that is needed to cure it. Antibiotics that have been shown to still be effective include clindamycin, trimethoprim/sulfamethoxazole, tetracycline, rifampin, and vancomycin.

The best way to prevent the infection is to wash your hands. Other preventive measures according to the CDC include keeping cuts and scrapes covered by bandages, avoiding using others' personal items such as towels and razors, and wiping surfaces of equipment at gyms or athletic departments before and after use.

References: please see above links.
Image courtesy of whaletobird.

Superbugs Are Superhackers

2007-10-22T08:53:00.000-07:00

Superbugs are no heroes. They are bacteria which have learned to decipher how to resist the antibiotic's effects. These bugs which previously had only one mechanism for fighting off an antibiotic have now developed multiple mechanisms for resistance. These mechanisms include developing cell walls that don't allow the antibiotic to penetrate the bacteria, pumps that quickly push out the antibiotic from the cell, and enzymes that deactivate the antibiotic. Superbugs can also exchange their survival information with other bacteria.

These bugs have been emerging for many years, and the movement has been spreading in the US and globally. Initially they were first noted in hospitals but now they have reached the community and have been detected in workplaces, gyms, and schools. Antibiotic overuse as well as misuse has been a major contributor to the emergence of these organisms. Some of these bacteria which have become more of a concern include methicillin-resistant staph aureus (MRSA), clostridium difficile (C. diff) , and gonorrhea.

Please keep these recommendations from the Mayo Clinic in mind to curb the expansion of this growing problem.

Understand when antibiotics should be used.
Don't expect to take antibiotics every time you're sick. Antibiotics are effective in treating most bacterial infections, but they're not useful against viral infections, such as colds or the flu. Each year in the United States, doctors write an estimated 50 million antibiotic prescriptions for viral illnesses for which antibiotics offer no benefit. And even some common bacterial ailments, such as bronchitis, don't respond well to antibiotics.

Take antibiotics exactly as prescribed.
Follow your doctor's instructions when taking prescribed medication, including how many times a day and for how long. Avoid stopping treatment a few days early if you start feeling better — a complete course of antibiotics is needed to kill all of the harmful bacteria. A shortened course of antibiotics, on the other hand, often wipes out only the most vulnerable bacteria, while allowing relatively resistant bacteria to survive.

Never take antibiotics without a prescription.
If you didn't complete a full course of antibiotics, you might be tempted to use the leftover medication the next time you get sick or to pass it along to someone else. But this is never a good idea. For one thing, the antibiotic might not be appropriate for your own or another person's illness. And even if it is, you're not likely to have enough pills to combat the germs making you sick, which can lead to more resistant bacteria.

Don't pressure your doctor for antibiotics if you have a viral illness.
Instead, talk with your doctor about ways to relieve the symptoms of your viral illness — a saline nasal spray to clear a stuffy nose, for instance, or a mixture of warm water, lemon and honey to temporarily soothe a sore throat.

Protect yourself from infection in the first place.
You can keep many germs at bay by adopting preventive habits, such as washing your hands thoroughly and often, handling and preparing food safely, and keeping up-to-date on immunizations.

Image courtesy of: invertebrates and microbes.

It's Time For Flu Vaccination

2007-10-18T11:45:00.000-07:00

The optimal time for influenza vaccination is from mid-October through November. However the vaccine may be given at any time until the end of the flu season which will be in April. Annual vaccination against influenza is the single most effective means of protection against the disease - 70-90% effective. It also reduces complications associated with the flu syndrome and helps protect those around you who are more frail and who are at higher risk of developing more severe cases of the disease. Each year in the US alone there are 20,000-36,000 deaths due to the flu.

The only new recommendation since this more detailed post of 2006 is that there has been a new California state law which mandates that pregnant women and children under 36 months should get the preservative free form of the flu shot. "Thimerosal, a preservative that contains a minute amount of mercury in compound form, is present in the standard flu vaccine (the classic "flu shot"). It is considered to be a safe vaccine component by the Center for Disease Control.

And in case you are still not convinced, you should know that it is expected to be a bad flu season this year. Australia had a several fold increase in flu cases earlier this year which usually is a good predictor of what is around the corner for us.

References: please see above links.

Image courtesy of: York Flu Clinic.

Say Ahhhh

2007-10-16T22:01:00.000-07:00

Sore throat (pharyngitis) is one of the top 10 reasons that patients visit doctors. Most of these patients are concerned about having developed strep throat. 70% of these patients get antibiotics. However, not all sore throats are strep throat. In fact only 5-15% of sore throats in adults are due to streptococcus pharyngitis.

The most common cause of sore throats are viruses especially the rhinovirus. Other viruses include coronavirus, influenza, adenovirus, herpes simples virus and less commonly the Epstein-Barr-virus associated mononucleosis. Antibiotics are not effective for viral pharyngitis.
Other causes include allergies, smoking, coughing or yelling excessively, gastroesophogeal reflux (heartburn), or low humidity.

However, it is important to detect the presence of strep pharyngitis because untreated strep may lead to complications such as rheumatic fever, acute glomerulonephritis (a type of kidney disease), peritonsillar abscess, and meningitis. It has even been associated in children with development of obsessive compulsive disorder or Tourette syndrome.

The gold standard of detecting strep group A is the throat culture. To avoid the 24-48 hour delay that occurs with standard throat cultures, a rapid strep test may be done. The sensitivity of this test is slightly lower than the throat culture.

Other clinical criteria besides the throat culture which may be used to determine if you have strep throat and therefore need treatment is the presence of 2 or more of the following:

tonsillar exudates (pus or white film) in the back of the throat
tender, enlarged, anterior, cervical nodes (glands in the neck)
absence of cough
fever
positive rapid strep antigen test

If none or only one of these criteria is present, then antibiotics are not recommended. Over the counter medications which may help soothe the sore throat include lozenges or cough drops, acetominophen (Tylenol) or ibuprofen (Advil/Motrin) , decongestants and antihistamines for congestion, and of course rest and fluids and minimizing talking.

Bad Relationships Increase the Risk of Heart Disease

2007-10-14T22:36:00.000-07:00

Here's another reason to work on your relationship. A new study from London concludes that the negative aspects of a relationship such as not confiding in or not feeling close to your partner can increase the risk of coronary heart disease by 34%.

Dr Roberto De Vogli (University College, London, UK) and colleagues studied 9011 British civil servants (6114 men and 2897 women) and assessed negative aspects of close relationships and other social-support measures with a questionnaire. Of these subjects, 80% cited marriage or a partnership as their closest relationship. Associations between negative aspects of relationships and coronary events were determined during an average of 12.2 years of follow-up.

After adjustment for a number of factors, including sociodemographic, biological (obesity, hypertension, diabetes, and cholesterol levels), and health behaviors (smoking, alcohol intake, exercise, and fruit and vegetable consumption), they found that people who experienced negative aspects of a close relationship had a 34% higher risk of incident coronary events than those who did not.

Although women and people in a lower socioeconomic classes were more likely to be exposed to negative aspects of a close relationship, there was not a significant difference in their risk for developing heart disease. Negative interactions in close relationships produced similar effects on coronary events regardless of sex and social position.

More studies are needed to examine the neuroendocrine and inflammatory changes which may be triggered by emotional events and therefore increase the risk of heart disease.

References: De Vogli R, Chandola T, and Marmot MG. Negative aspects of close relationships and heart disease. Arch Intern Med 2007; 167:1951-1957.

Image courtesy of: Richard Edwards, Angry Couple.

Chicken Pox

2007-10-09T23:12:00.000-07:00

What is chicken pox?

Chicken pox is a highly contagious disease that is caused by the varicella virus, a member of the herpes virus family. In temperate climates, chickenpox occurs most frequently in winter and early spring. It is common in the United States and worldwide. Virtually everyone who is not vaccinated acquires chickenpox by adulthood. The disease is usually more severe if acquired as an adult.

How is chicken pox transmitted?

Chicken pox is spread easily to others by direct person-to-person contact, by droplet or airborne spread of discharges from an infected person's nose and throat or indirectly by contact with articles freshly soiled by discharges from the infected person's lesions. The scabs themselves are not considered infectious.

How long can a person be contagious?

An infected person is most contagious from one to two days before the onset of rash until all lesions have crusted. People who are immunocompromised may be contagious for a longer period of time. The symptoms may appear any time between 10-21 days (but usually 14-16 days) after exposure to someone with chickenpox.

What are the symptoms of chicken pox?

Initial symptoms include sudden onset of mild fever and feeling tired and weak. These are soon followed by an itchy blister-like rash which appear in 3 or more successive waves. The blisters tend to be more common on covered than on exposed parts of the body. They may appear on the scalp, armpits, trunk and even on the eyelids and in the mouth. The blisters eventually dry, crust over and form scabs by 2-3 weeks from the onset of disease

Are there any complications to getting the disease?

Rarely the condition may be fatal particularly when it occurs in adults or persons with impaired immunity. The varicella virus can cause viral pneumonia and encephalitis (infection of the brain). A more common complication is infection of the blisters if they are scratched.

Once the virus invades the body, it lives in a sensory nerve ending quietly. However, under certain circumstances the virus can reactivate and multiply causing a severe blistering painful rash called shingles. The pain known as postherpetic neuralgia can last months to even years.

Also aspirin or aspirin containing products should never be given if chicken pox is suspected in children. It has been associated with a serious illness called Reyes Syndrome which can affect the liver and the brain and cause death.

Why is chickenpox a concern during pregnancy?

Most pregnant women are immune and are not at high risk. However a non-immune pregnant woman is at risk for chicken pox pneumonia which may occur in 10% of the cases and which can be life threatening.

If the exposure occurs during the first half of the pregnancy then there is a higher risk for birth defects to the child. This condition is characterized by skin scarring, malformed limbs, an abnormally small head, vision or hearing problems, and motor or mental developmental disabilities.

If the exposure occurs toward the end of pregnancy, between five days before giving birth, or two days after delivery, then the baby has a 30 to 40 percent chance of developing what's called neonatal varicella which can be life threatening, especially if left untreated. Fortunately, the risk of a severe case can be reduced if the baby is given a shot of varicella zoster immune globulin (VZIG), a blood product that contains chicken pox antibodies.

Does a past infection with chicken pox protect you from getting the disease again?
Chickenpox generally results in lifelong immunity. However, this infection may remain hidden and recur years later as shingles in a proportion of older adults and sometimes in children.

How can immunity be checked?

A simple blood test can be done to check the level of the antibodies present. The test may cost about $100.00 and it may not be covered by insurance.

What are the recommendations for the chicken pox vaccine?

The Advisory Committee on Immunization Practices (ACIP) recommends vaccination for chicken pox. For children under 13 years, two doses of vaccine are recommended. The first dose should be administered at 12 – 15 months of age and the second dose at 4 – 6 years of age. A second dose of catch-up varicella vaccination is recommended for children, adolescents, and adults who previously had received one dose. For anyone 13 years or older who has not had the disease, two doses of vaccine are recommended at an interval of 4-8 weeks. In case of uncertainty, prior varicella disease is not a contraindication to varicella vaccination.

Individuals who should not get the varicella vaccine include children with leukemia or other cancers, people whose immune systems may be weakened due to disease or medications, people taking high doses of steroid medications, pregnant women, and infants younger than 1 year.

How effective is the vaccine?

The vaccine is about 80% effective after the first dose and 99% effective after the second dose. Vaccine-induced immunity is believed to be long lasting.

Since the vaccine is not 100% effective, a modified varicella, known as breakthrough disease, can occur in some vaccinated persons. Breakthrough disease is most commonly (~ 70% - 80% of cases) mild, with fewer than 50 skin lesions, no fever and shorter duration of rash. . The breakthrough varicella is contagious and cases should be isolated for as long as lesions persist.

Administration of the vaccine to individuals within 72 hours of the disease may prevent or significantly reduce the severity of the disease.

What are the side effects of the vaccine?

The most common side effects are injection site complaints such as pain, soreness, redness, and swelling. A localized rash may also occur at that site. A generalized rash with a small number of lesions may rarely occur, within 3 weeks of vaccination. Fever may occur in 10-15% of the patients.

Varicella vaccine is a live-virus vaccine and results in a latent infection similar to that caused by wild varicella virus. Consequently, shingles caused by the vaccine virus has been reported. This appears to occur at a lower rate than following natural infection.

Women who have received the vaccine should not become pregnant for one month after the vaccination.

Can chicken pox be treated?

Acycolvir and other antiviral medications have been used to treat some individuals. In general they are not recommended for treating children since the disease is milder in children.

Oatmeal baths can help relieve itching.

Acetaminophen can be used to treat fever.

What's New In Bird Flu Vaccine Development

2007-10-07T17:12:00.000-07:00

There have been a few new developments in the production of the vaccine for the bird flu also known as avian flu (H5N1) virus over the last few months. In April the first vaccine in the United States for humans against the H5N1 influenza virus was approved by The U.S. Food and Drug Administration (FDA) . The vaccine is manufactured by sanofi pasteur. It is not currently being sold commercially. It has however been purchased by the government to be included in the National Stockpile program to be distributed by health professionals if needed.

This vaccine was obtained from a human strain of the virus. It consists of 2 injections given one month apart. Forty five percent of the individuals injected with the 90 microgram dose of the antigen, the active ingredient of the vaccine, developed an antibody level that was sufficient to reduce the risk of developing the disease. It is assumed that those who developed a lower antibody level may still have some protection and a reduced level of severity of the disease in case of exposure.

A challenge in developing the vaccine has not only been to create an active vaccine, but also to be able to supply the large number of people who may require it in a short period of time. The production of the antigen is a slow process, and one of the difficulties has been to produce an adequate amount of the antigen to provide the large number of doses of the vaccine that may be needed in a pandemic while ensuring adequate antibody level production that will be protective. To solve this problem, many companies have been working on adding an additive, an adjuvant, to the vaccine that will help increase the immune system's response to a lower dose of the antigen.

Last month Sanofi announced that its new investigational H5N1 vaccine containing an adjuvant achieved a high immune response at the lowest dose of H5N1 antigen reported to date. The vaccine containing only 1.9 micrograms of antigen generated an immune response in over 70 percent of the participants in a clinical trial, and the vaccine containing 3.75 microgram of antigen generated a high level of immune response in over 80 percent of the participants. Preliminary data also show good cross-reactivity to a more recently circulating H5N1 strain.

This is an important development in the vaccine production. It may facilitate the production of billions of doses of the fully developed vaccine in a short time if needed in a pandemic situation.

Sinusitis - When to Start Antibiotics

2007-10-04T00:53:00.000-07:00

How many times have you visited your doctor saying, " Doc I have a sinus infection - I need antibiotics". Looking at this picture, it's easy to understand why you would want to get the whole thing over with as quickly as possible. It's gnarly.

Chances are that you are one in the 30-35 million patients a year who develop acute bacterial sinusitis. Symptoms of this condition are severe pain and pressure in the face, forehead, and upper teeth as well as a purulent discharge that drains out of the nose and slips behind the throat causing a nasty taste and nausea. It can make it difficult to concentrate, work, or sleep.

"Quick give me the antibiotics now - I'm launching a project and can't afford to get sick." However, it turns out that once you have this condition there is a natural course that it follows. Antibiotics started before 7 days do not help expedite improvement. Antibiotics are beneficial only if the symptoms of the sinusitis have persisted beyond 7-12 days. Before 7 days, antibiotics do not offer an advantage in treatment. They may however, cause more side effects such as diarrhea, stomach upset and rashes which only compound the suffering.

There are measures other than antibiotics which may help resolve the sinusitis. These include taking decongestants or performing nasal irrigation.

So Googlers and non-Googlers alike, next time you call your doctor about your sinusitis symptoms please take into account as to how many days you have hosted the bug. Have you given the organism proper time to leave on its own terms? If yes, you should be better by 7 - 12 days. If not, then it may be time for an attack via pharmaceutical launches.

Reference: Title: Systematic Review of Antimicrobials for Acute Rhinosinusitis Authors: Michael C. Singer, MD, Richard M Rosenfeld, MD MPH, Stacie Schilling Jones MPH Date: Tuesday, September 18, 9:58 am - 10:06 am presented at the 2007 AAO-HNSF Annual Meeting & OTO EXPO.

Photo: courtesy of MayoFoundation.

Do You Need Antibiotics Before Dental Procedures

2007-10-01T21:54:00.000-07:00

Until recently, the American Heart Association (AHA) recommended that patients with certain heart conditions take antibiotics before dental procedures such as cleaning and extractions to prevent infection of the heart valves know as infective endocarditis.

However, according to the latest guidelines which were published in Circulation, in April 2007, the AHA recommends that most of these patients no longer need antibiotics as a preventive measure before their dental treatment. These recommendations were based on a comprehensive review of studies which did not show a strong correlation between the use of antibiotics prior to dental procedures and the risk of developing infective endocarditis in those who were at risk for developing this infection. These patients are already often exposed to bacteria from the mouth, which can enter their bloodstream during basic daily activities such as brushing or flossing.

Patients who have taken prophylactic antibiotics in the past but who may no longer need them include people with:
--mitral valve prolapse
--rheumatic heart disease
--bicuspid valve disease
--calcified aortic stenosis
--congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

Patients who are still advised to get the antibiotics are anyone with:
--artificial heart valves
--a history of infective endocarditis
--certain specific, serious congenital (present from birth) heart conditions, including
unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
--a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
--any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
--a cardiac transplant that develops a problem in a heart valve.

Google's Top 50 Blogs

2007-09-27T21:07:00.000-07:00

It's nice to see that health does count in the tech world.

Psoriasis - Answering Your Questions

2007-09-27T00:35:00.000-07:00

Dr. Patricia Wong, an established Palo Alto dermatologist, has been kind enough to share her expertise on psoriasis with us. She has treated many patients with this condition, and hopes that this information will be helpful to anyone with psoriasis or anyone who knows of someone with psoriasis.

What is psoriasis?
This chronic inflammatory skin condition affects approximately 2% of the population. The process involves rapidly replicating skin cells. New skin cells are produced about eight times faster than normal--over several days instead of a month--but the rate at which old cells slough off is unchanged. This causes red, scaly patches which can be itchy. It can have widespread involvement of the scalp, nails, skin, and joints. Patients can feel very self-conscious about their appearance especially if the involvement is extensive or in exposed areas. The scaling and redness can be a source of embarrasment.

What causes psoriasis?
Psoriasis is caused by genetic, immunologic and environmental factors. Individuals may have several disease genes which require environmental trigger factors to activate the psoriasis. These triggers may include stress, Strep throat infection, and certain medications. No clear inheritance pattern is seen. Patients who have early onset psoriasis demonstrate a significantly higher frequency of HLA -Cw6 major histocompatability complex located on the short arm of chromosome 6 (for those of you who really like the details) . Sixty percent of the patients develop psoriasis before the age of 30. Age of onset has 2 peaks, between 20- 30's and mid 50's to 60's. Early onset psoriasis has a stronger family linkage and a tendency to become more extensive. Late onset psoriasis tends to be sporadic and usually milder.

Is it contagious?
No. You cannot develop psoriasis from touching someone that has it nor spread it to other parts of your body by touching. It is not a sexually transmissible disease.

Do I have it because I am doing something wrong?Can I be cured?
Psoriasis is not curable but it is treatable; with proper treatment often the psoriasis will clear or even go into remission for long periods of time. Psoriasis can spontaneously go into remission. This means it may disappear for a while and then recur. The length of remission varies considerably but long term remissions are rare.

What can I do to treat it?
It is advised to see a dermatologist rather than a general practitioner as the treatment of psoriasis may be complex. Treatment varies depending on the specific body areas involved and the extent of involvement. Individuals vary in their response and tolerance to the different medications.

Localized psoriasis generally requires localized treatment - topical medication or localized phototherapy. Multiple agents are available including tar, anthralin, topical corticosteroids, topical vitamin D and Vitamin A analogues, topical immunomodulators and keratolytics such as salicylic acid. One of the main reasons psoriasis is difficult to treat is that patients find the treatments time consuming, messy, greasy and become frustrated. Compliance decreases over time as individuals become weary of continuing their treatment.

Extensive psoriasis requires phototherapy or systemic treatment. There are many oral medications available and each has its advantages and potential side-effects. Acitretin, methotrexate, cyclosporine, mycophenolate mofetil are some of the medications commonly used. There are also new biologic medications available that can be administered by the patient as an injection. These are expensive but can help clear stubborn psoriasis that has not responded to the above mentioned medications. These include alefacept, etanercept, and adalimumab.

Where is a reliable source of information?
The National Psoriasis Foundation is an excellent resource and offers a variety of brochures and newsletters. Anyone can join, even without paying, though there is a recommended donation of $27 to cover mailing costs. Their address is 6600 SW 92nd Avenue, Suite 300 Portland, OR 97223-7195 USA . Telephone number 1-800-723-9166.

What can I expect from the disease?
While the quality of life can be greatly impacted, very few people actually die from psoriasis. There appears to be an increased rate of obesity, higher levels of depression, and alcohol misuse in psoriasis patients which may be related to the emotional burden of having a stigmatizing disease. Alcohol and smoking cigarettes can destabilize the disease and make it very difficult to treat. It is strongly advised to consult with a dermatologist as psoriasis is a treatable condition and can be improved or potentially cleared with treatment. You do not need to feel victimized by psoriasis.

What suggestions do you have for coping with this problem emotionally?
There are several points to consider: the feeling of having no control over the psoriasis, the bothersome aspects of complying with the treatment program, and the social stigmatism. You need to find a dermatologist who understands how the psoriasis is affecting you and let them know to what extent you are willing to commit in terms of time, energy, and risks to deal with it. Your dermatologist can help you decide the most effective route of treatment. You should be active in dealing with it and not let the sense of isolation and stigmatization overwhelm you and interfere with treating the psoriasis.

Passing Gas

2007-09-24T22:20:00.000-07:00

We all do it, some more than others, and it is a common complaint in my office. Well I mean it is a common complaint that I hear from my patients who are seeking care about flatus (gas that is passed from the anus) as opposed to gas that is passed from the mouth(belching or burping) and gas that is stuck in purgatory(bloating).

What is the normal amount of gas to pass?
It is normal to pass gas 6-25 times a day.

What is gas?
Intestinal gas is made up of oxygen, nitrogen, carbon dioxide, hydrogen, ammonia, methane, and hydrogen sulfide. The latter 3 gases account for the more toxic levels of the odor. The composition of the gas varies depending on the types of intestinal bacteria that are present.

What produces gas?
The large intestine (colon) contains many bacteria, fungi, and yeast. As food passes through the intestinal tract, some of the carbohydrates remain undigested as they reach the large intestine. These organisms enjoy the undigested carbohydrates and break the carbohydrates down and produce gas as the byproduct.

What increases gas?
The most common factors which contribute to gas production are eating patterns and bacterial composition of the intestine.

Foods that cause an increase in gas production include:
--Milk products especially if you are lactose-intolerant which means that you do not have the enzyme lactase needed to digest the carbohydrate, lactose.
--Carbonated beverages
--Spicy, fried or fatty foods
--Broccoli, cabbage, onions, celery
--Beans
--Apple or prune juice
--Dried fruits
--Anything containing sorbitol, mannitol or maltitol, found in many low-carb or sugar-free foods

Other factors that increase gas production include:
--Anything that increases swallowing of air such as talking while eating, chewing gum or sucking on candy, using a straw or sports bottle, deep sighing, smoking or chewing tobacco, or ill fitting dentures.
--Tight-fitting garments
--Long-term use of medications for relief of cold symptoms
--Smoking or chewing tobacco
--Overloading your stomach
--Hormonal changes such as during menstrual cycle
--Constipation or Irritable Bowel Syndrome

What decreases gas?
Other than altering the flatugenic behaviors already mentioned, these remedies may be helpful.
--Lactase found in products such as Lactaid can be taken to help with the digestion of lactose when consuming dairy products.
--Beano contains the enzyme which breaks down raffinose, the carbohydrate in beans.
--Simethicone (Gas-X, Mylicon) breaks down the gas bubbles to help dissolve them.--Some natural remedies include peppermint and chamomile tea, fennel, anise, and turmeric.
--Fiber products such as Metamucil and Citrucel may also be helpful if Irritable Bowel Syndrome is present. However, these products may initially increase gas.

It is advised to seek medical attention if gas production is accompanied by weight loss, diarrhea, vomiting, heartburn or blood in the stool, or if there is an increase in frequency, location or severity of the symptom.

References: Brigham and Women's Hospital.
Photo: courtesy of Medline.

Contaminated Tofu Recall

2007-09-24T21:50:00.000-07:00

Soy Deli Tofu produced by Quong Hop & Co. of South San Francisco, Calif., has been recalled due to contamination with Listeria monocytogenes.

Listeria is a bacteria that can cause serious or fatal infections such as meningitis (infection of the lining of the spinal cord) or encephalitis (infection of the brain membrane) as well as intrauterine infections in pregnant women which may lead to stillbirths or miscarriages in the 2nd or 3rd trimester.

The symptoms usually begin with influenza-like symptoms including persistent fever, headache, nausea, vomiting and diarrhea. The incubation time to serious forms of listeriosis is unknown but may range from a few days to three weeks. The symptoms may be more severe in children, the elderly and those with immunosuppression. No illnesses have been reported in connection with the products according to the company.

The packages which have been recalled are coded Dec. 17, 2007 and Sept. 23, 2007: the 30-ounce Soy Deli nigari tofu, the 12-ounce Soy Deli water packed tofu and the 16-ounce Quong Hop water packed tofu.

Lybrel - A Continuous Oral Contraceptive

2007-09-23T22:21:00.000-07:00

The FDA recently approved Lybrel, a new oral contraceptive, which is taken continuously through the year without a pill-free interval. The pills contain levonorgestrel (.09 mg) and ethinyl estradiol (20 mcg).

This type of regimen may be useful in women in whom oral contraceptives are used to treat painful menses (dysmenorrhea), endometriosis, acne, and polycystic ovary syndrome. It may also be more effective than cyclic contraceptives in improving menstrual related headaches and mood changes.

Continuous oral contraceptive use should eventually eliminate menstruation. However, unexpected bleeding is the most common side effect. The incidence of breakthrough bleeding decreases with time. In clinical studies, about half of the women had bleeding at pack 3, and 20% at pack 13.

It should be noted that the long-term effects of continuous regimens have not been evaluated.

References: please see links.

Photo: courtesy of Slate.

Dog Strain Rabies Eliminated In the United States

2007-09-19T21:02:00.000-07:00

The Centers for Disease Control and Prevention (CDC) has declared the elimination of the type of rabies previously found in dogs in the United States. This does not mean that all rabies has been eliminated or that dogs should stop being vaccinated. Animals in the wild such as bats, skunks, and raccoons carry rabies and can infect dogs and humans. However, this is a public health success story which reflects the efforts of many in the implementation of dog vaccination and licensing, and stray dog control.

Rabies is a viral disease that reportedly kills 55,000 people globally every year. Infection is usually through a bite (saliva)from the rabid animal. The virus infects the nervous system and causes encephalopathy (swelling of the brain) which leads to death. The incubation period in humans is typically one to three months, and possibly up to one year or more. Symptoms include fever and headache followed by insomnia, agitation, confusion, paralysis, hallucinations, and hydrophobia (fear of water). Once symptoms appear, death usually follows a few days later. It can be prevented with a vaccine but once symptoms emerge it is too late and death is inevitable as the disease is almost impossible to treat.

References: Center for Disease Control.
Photo: Courtesy of Chorley Council.

Evista Approved to Reduce the Risk of Breast Cancer In Postmenopausal Women

2007-09-17T22:26:00.000-07:00

The U.S. Food and Drug Administration has recently approved Evista (raloxifene hydrochloride) for reducing the risk of invasive breast cancer in postmenopausal women with osteoporosis and in postmenopausal women at high risk for breast cancer. Evista is only the second drug approved to reduce the risk of breast cancer. Tamoxifen was the first.

Evista has been on the market since 1997. It has been used for the prevention and treatment of osteoporosis.

The decision to approve Evista for this new indication was based on several large clinical trials. In one trial involving about 15,000 postmenopausal women, Evista was shown to reduce the risk of invasive breast cancer by 44 to 71 percent when compared to placebo. In another study of almost 20,000 women with high risk for breast cancer, Evista was compared to Tamoxifen. Evista was equal to Tamoxifen in preventing breast cancer.

A recent trial found that Evista does not raise the incidence of stroke, but does the incidence of death due to stroke. A boxed warning now says "women with an active or past history of venous thromboembolism should not take EVISTA.. Women at risk for stroke should receive EVISTA only after evaluating the risk-benefit balance with their healthcare providers."

References: U.S. Food and Drug Administration.

Omega 3, Fish and Mercury - Is Fish Safe to Eat?

2007-09-16T13:12:00.000-07:00

Omega-3 fatty acids have been reported to have a beneficial effect on cardiovascular disease (CVD) . This effect has been reported in patients with preexisting CVD as well as in healthy individuals. A number of countries (Canada, Sweden, United Kingdom, Australia, Japan) as well as the World Health Organization have made formal population-based dietary recommendations for omega-3 fatty acids.

Foods that are rich in omega 3 fatty acids include fish, canola and olive oil, soy, flax seed, and walnuts. Most of the studies which show the health benefits of omega 3 have been correlated with fish consumption. Omega 3 fatty acids can be categorized into plant-derived omega 3 fatty acids ( -linolenic acid) and marine-derived (eicosapentaenoic acid [EPA] and docosahexaenoic acid[DHA]) omega-3 fatty acids. Typical recommendations for daily intake of linolenic acid are 0.8 to 1.1 g. Recommendations for EPA and DHA are 0.3 to 0.5 g/d and up to 1.2 grams if there is a history of heart disease or cholesterol abnormality.

Fish are the major food source of EPA and DHA. All fish contain EPA and DHA. However, some species of fish may contain significant levels of methylmercury, polychlorinated biphenyls (PCBs), dioxins, and other environmental contaminants. Exposure to PCBs can be reduced by removing the skin and fat from these fish before cooking them; however, because mercury is distributed throughout the muscle it is not possible to remove it from the filet. Fish that are highest in mercury concentration are the large predatory fish such as swordfish, King mackerel, shark, and tilefish. This chart shows the different levels of mercury associated with different types of fish.

The benefits and risks of eating fish vary depending on a person’s stage of life. In general it is advised that children and pregnant and nursing women avoid potentially contaminated fish because this group is at a lower risk for cardiovascular disease but at a higher risk of exposure to mercury. For middle-aged and older men, and women after menopause, however, the benefits of eating fish far outweigh the risks within the established guidelines . Eating a variety of fish will help minimize any potentially adverse effects due to environmental pollutants.

Here's a video about omega 3 from a medical student.

References: Circulation. 2002;106:2747. U.S. Environmental Protection Agency. American Heart Association.

What's Wrong with Trans Fatty Acids

2007-09-10T23:54:00.000-07:00

The New York City Board of Health has recently required that restaurants reduce the content of trans fatty acids so that each serving contains less than 0.5 grams. A recent study in the New England Journal of Medicine showed that a 2% increase in caloric intake from trans fatty acids was associated with a 23% increase in the incidence of coronary artery disease. The association is stronger with heart disease than it is with saturated fats.

What are trans fatty acids? Naturally occuring fats consist of saturated and unsaturated fatty acids. Unsaturated oils (vegetable oils) are converted to the trans form by partial hydrogenation to increase their stability and to raise the melting point. This process converts vegetable oils into semisolid fats for use in margarines, commercial cooking, and manufacturing processes.

Why are trans fatty acids bad for you? Previously it was assumed that trans fatty acids would be healthier than saturated fats, but they have been shown to decrease HDL cholesterol (the good cholesterol) and increase LDL cholesterol (the bad cholesterol). They also cause damage to the lining of blood vessels. In addition they have shown to promote abdominal fat depostion and insulin resistance both of which are early changes in the development of type 2 diabetes.

Where are trans fatty acids found? Deep fried food, packaged snacks, and bakery products are the major sources of trans fatty acids in the US. The average daily intake in the US is about 2.6 % or 6 grams in a typical 2000 calorie diet. The American Heart Association recommends limiting intake of trans fatty acids to 1% of daily caloric intake. Deep fried fast-food products may include 10 grams per serving.

How to avoid the bad fats? The American Heart Association recommends the following:

--Choose a diet rich in fruits, vegetables, whole-grain, high-fiber foods, and fat-free and low-fat dairy most often.
--Keep total fat intake between 25 and 35 percent of calories, with most fats coming from sources of monounsaturated and polyunsaturated fats such as fish, nuts, seeds and vegetable oils most often.
--Use naturally occurring, unhydrogenated vegetable oils such as canola, safflower, sunflower or olive oil most often.
--Look for processed foods made with unhydrogenated oil rather than partially hydrogenated or hydrogenated vegetable oils or saturated fat.
--Look for ”0 g trans fat” on the Nutrition Facts label.
--French fries, doughnuts, cookies, crackers, muffins, pies and cakes are examples of foods that are high in trans fat. Don't eat them often.
--Limit the saturated fat in your diet. If you don't eat a lot of saturated fat, you won't be consuming a lot of trans fat.
--Limit commercially fried foods and baked goods made with shortening or partially hydrogenated vegetable oils. Not only are these foods very high in fat, but that fat is also likely to be very hydrogenated, meaning a lot of trans fat.
--Commercial shortening and deep-frying fats will continue to be made by hydrogenation and will contain saturated fat and trans fat. That's just one more reason to eat fried fast food infrequently.

References: The Medical Letter, vol 49 (issue 1267), August 13, 2007. Please see above links.

Photo: courtesy of University of Pennsylvania Health Systems.

More Spinach Recall

2007-08-29T22:48:00.000-07:00

This California based company is recalling their fresh spinach packages as a precautionary measure after routine testing showed salmonella in one of the product lines.

The spinach is distributed throughout the 48 states and in Canada. So far there have not been any reports of illness.

Salmonella is a bacteria that is transmitted to humans by eating foods that are contaminated by animal or human feces. It does not cause any change in the smell or taste of the food that it infects. It is the most frequently reported cause of food borne illnesses in the US - 1.4 million cases annually.

Symptoms of salmonella infection include diarrhea, cramps, fever, and vomiting. The symptoms may be much more severe in young children, the elderly, and in the immunocompromised patients. Although the illness may resolve spontaneously after 7 days, it may take several months before the bowels return to normal. A small percentage of the people may also develop joint pain, painful urination, and eye irritation that may last for months to years.

For more information you can contact Metz Fresh at 831-386-1018.

Photo: courtesy of spinnychips
Disclaimer: my apologies if the language in the video section is offensive to anyone.

Hepatitis A Infection in San Jose, California

2007-08-26T23:38:00.000-07:00

Many of us get vaccinated for Hepatitis A only when we travel, but you don't have to go far to get this virus. Recently a food handler who worked at Jamba juice at 1140 Lincoln Ave in San Jose (Willow Glen), California has been diagnosed with hepatitis A infection. The food handler was contagious while he was working during several dates in August. Anyone who consumed juice at that site on August 1-3, 6-9, 11, 13-16 may have been exposed to hepatitis A although the risk is low.

Persons who have had the vaccine for hepatitis A in the past or the disease itself are immune and do not need to take any further action.

Those who have never had the vaccine or the disease should be aware of symptoms of Hepatitis A such as fever, fatigue, abdominal pain, nausea, diarrhea, and jaundice (a yellowish tint) to the skin and to the eyes. The incubation period varies from 15-50 days. Hepatitis A vaccine can still be given to protect against future exposures to hepatitis.

If you have any questions please call The Santa Clara County Public Health Dept's Disease Prevention and Control at 408-885-3980.

Red Yeast Rice - Is It Safe?

2007-08-19T22:29:00.000-07:00

Red yeast rice is a supplement that is used to reduce cholesterol. It is effective because it contains "Monacolin K" a potent inhibitor of HMG-CoA reductase, also known as Lovastatin (Mevacor®, a drug produced by Merck & Co., Inc). It has been used in China since 800 AD.

There has been some dispute as to whether red yeast rice should be classified as a supplement or as a drug. Recently the FDA recommended to "avoid using" the products because they "may contain an unauthorized drug that could be harmful to their health."

However, with careful monitoring the risk of taking this medication should be low. To reduce the risk of liver and muscle injury which are two of the common side effects, patients should inform their physicians that they are using this supplement. A routine blood test can be done to monitor for any evidence of injury. Patients who are already on a cholesterol reducing medication should be aware that taking this supplement may increase their risk of side effects.

References: please see links.

Photo: courtesy of Solaray.

Attention: Marijuana Smokers

2007-08-10T00:07:00.001-07:00

The active component of marijuana, '-9 tetrahydrocannabinol (THC), has been associated with an increased risk of Kaposi's sarcoma according to the August 1 issue of Cancer Research. Researchers at Harvard Medical School showed that low doses of THC could enhance the ability of the virus that causes Kaposi's sarcoma to infect cells and multiply. People who are most at risk for this infection are those with lowered immune systems, such as AIDS patients or cancer or transplant patients who are on chemotherapy or on immunosuppressants. Since this patient population may also use marijuana for pain control, they or others with weakened immune systems who use marijuana recreationally should consult their doctors regarding the benefits and risks of marijuana use.

References: please see links.

Photo: courtesy of Men's Health.

Sodas and Heart Disease?

2007-07-24T12:51:00.000-07:00

There have been several news reports since yesterday on the findings of a study which concluded that people who drink more than one soda a day - diet or regular- have a higher chance of heart disease.

I'm not a big fan of sodas, but since diet sodas help reduce the daily calorie intake, I'm concerned that people who consume diet sodas will come to the wrong conclusion based on the superficial news coverage of this study. The data does not show any cause and effect. It simply demonstrates an association. It may be that people who are drinking sodas are already following a less healthy lifestyle and therefore have a higher association with heart disease. Given the epidemic of obesity and its impact on heart disease and diabetes, it seems that the risk benefit ratio is still in favor of the diet sodas.

As for regular sodas, there is no reason to drink them as far as I'm concerned.

References: please see links.

"Long Weekend" Supplements Recalled

2007-07-21T11:05:00.000-07:00

Long Weekend, Confidence, Inc, a dietary supplement, is being recalled after the FDA found tadalafil in product samples.

Tadalafil is also known as Cialis (Eli Lilly and Company). It is approved for the treatment of erectile dysfunction (ED). However, it should not be used in combination with nitrate containing medications which are often used for heart disease or high blood pressure. Unintentional consumption of tadalafil by patients receiving nitrates may cause potentially dangerous hypotension which may lead to a stroke or heart attack.

The product was sold through mail order and at retailers located in the United States, Puerto Rico, Canada, the United Kingdom, Russia, and China, and marketed as 3-capsule boxes under the American Best Nutrition label (UPC 809515-0542).

Adverse reactions related to the use of this product should be reported to the FDA's MedWatch reporting program, by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787. This information can also be communicated to the company by calling 1-800-347-5005.

References: FDA

Multitasking

2007-06-27T20:35:00.000-07:00

This is one amenity that I don't want to see at Google - although I confess that I could use it. I've been absent from the blog, and I have been guilty of multitasking.

As the lack of my postings demonstrate, multitasking results in less productivity despite the delusion that more work is being done. There is a large body of evidence that shows that we perform worse when we multitask. The brain by design is limited in concentrating on more than one thing at once. We perform and learn differently when we are multitasking.

Researchers at University of Michigan and Federal Aviation Administration studied patterns in the amounts of time lost when people switched repeatedly between two tasks of varying complexity and familiarity. The results showed that for all types of tasks, subjects lost time when they had to switch from one task to another.

In another study at Vanderbilt University participants were given tasks one at a time and then two at a time. There was a one second delay in response to the second task when the tasks were given at about the same time. There was no delay when the tasks were given one at a time. The one second delay may seem unimpressive, but it can be the difference between life and death in a hazardous traffic situation.

In today's world, multitasking is inevitable. However, it is wise to be aware of multitasking's limitations as well as the personal toll that it takes. Experts suggest turning off the cell phone when driving, ignoring the blackberry when having meals with family and friends, answering email at specific times only, and maybe not lining up 48 hours in advance for the iphone.

References: please see links.

Photo: I've lost the reference. If anyone has it, please send it.

Itchy Eyes

2007-05-03T21:38:00.000-07:00

We are heading into peak allergy season and a common problem is itchy eyes.
Dr. Neil Friedman, our guest blogger and ophthalmologist has a few words of advice.

Q: I have terrible allergies and my eyes are constantly itchy. Visine doesn’t seem to help at all. Is there anything else I can use?

A: Allergies plague many of us with the all too familiar symptoms of itchy eyes, running nose, tearing, sneezing, and congestion. There are over-the-counter (OTC) as well as prescription remedies available to treat allergic rhinitis, but with varying effectiveness for the eye involvement. Nonprescription eye drops to stop the redness and itching can alleviate symptoms temporarily, but eventually become ineffective with long-term use. The good news is that there are numerous prescription antihistamine drops that work better and are gentler to the eye.

Whether it’s an allergy to pets or to plants, seasonal or year round, the allergic response in the eyes is called allergic conjunctivitis. The eyes become itchy and red with varying amounts of swelling, tearing, and white, stringy discharge. Occasional use of the OTC eye drops can be tried, but resistance and an eventual rebound affect with more redness may occur with frequent, chronic use. Prescription topical antihistamine eye drops have been available for years. These preparations are more effective, longer lasting, safer, and better tolerated than their OTC counterparts because they have a dual or triple mechanism of action, blocking the allergic response at multiple levels. Usually just one or two drops provide all day relief. These medicines do not work equally in everybody, but there are enough choices that one which works for you can usually be found.

For severe allergic symptoms that do not respond to the antihistamine drops, temporary use of steroid eye drops is highly effective. For eyelid swelling, the application of cold compresses is soothing and also helps reduce itching. Therefore, with current treatments for allergic conjunctivitis, there’s no longer any need to suffer with itchy, watery eyes.

High Blood Pressure with High Job Strain

2007-04-16T20:59:00.000-07:00

How are you feeling on the job? Are you feeling that you don't have control or that your decision making latitude is limited? If the answer is yes, then you may be developing high blood pressure.

A recent study published in Journal of Environment and Occupational Medicine showed that high job strain is linked to high blood pressure. The researchers led by Els Clays, M.Sc., of Ghent University in Belgium, identified 89 workers with high job strain and an equal number of workers without high job stress. Blood pressure readings of both groups were then monitored with a 24 hour ambulatory blood pressure monitor at regular intervals as they went through their daily activities.

Those with a high strain showed a significant increase in their blood pressure. The relationship between job strain and higher readings remained intact even after other factors such as age, obesity or smoking were adjusted. Interestingly enough, the high blood pressures were related more to feeling a lack of control than to high job demand alone.

So what can you do? Ask your doctor to check your blood pressure. Reduce your stress level by exercising and learning relaxation techniques such as breathing exercises. Jobs may come and go, but your health is irreplacable.

References: please see links.

Two Medications Better than One for Migraines

2007-04-10T22:36:00.000-07:00

A recent study published in the Journal of American Medical Association concluded that the combination of 2 medications may help relieve the symptoms of migraine more effectively than one medication alone.

In this multi-center clinical trial, patients with moderate or severe migraine attacks were randomized to receive either a fixed dose of sumitriptan plus naproxen, sumitriptan, naproxen or placebo.

Patients were then evaluated for absence of headache 2 hours after dosing as well as for the absence of nausea, photophobia, and phonophobia which are often associated with migraine headaches.

The combination of sumitriptan plus naproxen had a more favorable outcome than the use of either medication alone.

Although at first glance this may seem obvious, often headache symptoms are treated with one medication and the dosage is then continuously increased until the desired effect is reached.
However, a lower dose of 2 medications may have more benefit and possibly less side effects than one medication which is used at a higher dose. This may be due to the fact that the pathogenesis of migraines, although not well understood, has multiple causes and pathways which lead to the severe and disabling headaches that at least 28 million Americans experience.

Photo: courtesy of bibliophilebullpen
References: please see specific links above.

Ready to Run?

2007-04-01T21:19:00.000-07:00

Dr. Anthony Luke , Director of Primary Care Sports Medicine at University of California, San Francisco, practices what he preaches. I'm delighted that one of San Francisco's premier sports medicine specialists has agreed to share his expertise as our guest blogger.

Spring is here! Though the Bay Area allows people to run all year, many people here and around the country are putting on their running shoes and heading for their local trails. What steps can you take to run safely and try to prevent injuries?

Warm up before running. Jogging at 1/2 or 2/3 speed for 2 or 3 minutes before getting in your normal running pace can warm up the muscles which has been shown to improve flexibility and resistance to stretch injuries.

Stretch for flexibility during your cool down. Spend a few minutes stretching the major muscle groups when you are done, for example, the calf muscles, hamstrings, quadriceps, hip flexors and iliotibial bands. Research really hasn't shown that stretching before exercise prevents injuries. However, tight muscle groups have been associated with several injuries. Studies have shown that one stretch of 30 seconds is better than three times at 10 seconds and as good as three times at 30 seconds. So hold each stretch for 30 seconds at least once and move on to the next.

Strengthening. Important muscles to strengthen for runners include the calf muscles, quadriceps, hamstrings and the gluteal muscles! People often forget the muscles that rotate the hip, which are important stabilizers for the leg. Also, core stability is key so work on your abdominals. The large exercise balls are excellent training tools.

Get the right shoes. Go to a store that has salespeople experienced with runners and proper shoe fitting. The soles of most running shoes have a lifespan for around 400-500 miles.

Fluids and Fuels. Keep track of your diet. Replacing necessary energy using carbohydrate sources such as gels or bars are needed especially when you're running longer than 90 minutes. Proper hydration before, during and after running is essential. You should learn how much fluid you need during your training runs and alter things depending on how hot the weather is.

Got injuries?

If you:

1) have pain greater than 2 hours

2) have swelling

3) need to change your running technique

Take a break. Try cross training on a bike or swimming. If you rest for a week and still can' run, it's time to talk to someone who knows about running injuries. Your local sports medicine expert can help.

Healthy Travel - Plan Ahead

2007-03-27T21:07:00.000-07:00

Although less than 1% of travelers require hospitalization, 70% of those traveling in less developed countries report an illness during their trip. Here's your check list to help prevent many of the illnesses.

Before you take off:

1. Vaccines.
-- See your doctor 4-6 weeks before your date of departure. Bring any immunization records that you may have to your visit.
-- Vaccine recommendations vary by country. Here are the links for India, China, Brazil, and Ghana. For other countries check the CDC site. Europe, Australia, Canada, and USA do not need any further vaccines than what are recommended during routine health care immunizations.

2. Prescription medications.
-- If you are going for an extended period of time you may need to contact your insurance company to get approval for a longer course of your medications such as birth control pills, allergy medications, or inhalers for asthma.
-- Antibiotics such as Cipro for diarrhea type illnesses are useful. Azithromycin can be used for respiratory or skin infections. It can also be an alternative for Cipro.
-- Epinephrine kit if you have severe allergic reactions to bee stings, food or drugs is necessary.
-- Sterile needle/syringe kit if traveling to an area where the sterility of instruments may be in question.

3. Over the counter medications.
-- Loperamide (Imodium) for diarrhea.
-- Diphenhydramine(Benadryl) for allergic reactions, motion sickness, nausea, and as sleep aid.
-- Loratidine (Claritin) for allergic reactions. Lasts longer than Benadryl and is not sedating.
-- Hydrocortisone for skin reactions.
-- Sudafed for congestion, especially if before a flight.
-- Acetominophen(Tylenol), Ibuprofen(Advil) or other anti-inflammatory medication such as aspirin for pain, fever, joint swelling.
-- Metamucil for constipation.
-- Medical kit including a thermometer, band aids, antibiotic ointment, a roll of gauze, tape, and small scissors, oral re hydration salts such as CeraLyte for severe dehydration, hand sanitizer gel or towelettes, tweezers, and extra pair of glasses.

4. Protective gear.
-- Mosquito repellent. 30% DEET containing repellents are recommended for adults. Read here for more details .
-- Proper clothing. Sporting good stores such as REI have permethrin permeated clothing as well as special materials which allow more comfortable temperature control.
-- Sun protection. SPF of 30 is recommended by most dermatologists. Read here for more details.
-- Condoms if you plan to be sexually active but please be aware that they are not 100% protective.

5. In case of pre-existing medical conditions.
-- Pregnancy. Most airlines don't allow travel after 35 weeks of pregnancy. Pregnancy by itself is not a contraindication to travel. Please check with your obstetrician if you have had any complications during your pregnancy.
-- Asthma and respiratory diseases. If your condition is well controlled then there should not be any difficulty with travel. If you are breathless or cannot walk 50 meters (164 ft.) then you should seek medical advice before travel. During take off, the slight drop in oxygen pressure may cause problems for certain chest conditions.
-- Diabetes. Meals should be arranged with airline before travel. During the trip, stay on home time with regard to medication regimen, but after landing adjust to local times.
-- Heart disease. In general if you are able to walk up a dozen stairs then you should not have any trouble on a flight. If you have had a recent heart attack or stroke then you are advised not to fly without consulting your doctor.

On the plane, train, or automobile:

1. Gas.
As cabin pressure falls, the air in the intestines expands by as much as 25% and causes bloating and discomfort. Avoid carbonated drinks, and eat and drink in moderation during a long flight. If you have a severe problem with gas, then you can try over the counter medications which contain simethicone such as Gas-X.

2. Motion sickness.
Eat small but frequent snacks to reduce nausea. Scopolamine (in patches or pills) and medications for nausea and vomiting such as promethazine may be prescribed by your doctor.
These medicines do cause drowsiness and should not be taken with alcohol.

3. Blocked ears.
Can be relieved by swallowing, sucking on hard candy, chewing gum, or holding your nose and blowing. Sudafed tablets and Afrin nasal spray can also help relieve the blockage if taken ahead of time, about 30-60 minutes before take off or landing. If you suspect an ear or sinus infection before your trip, consult your doctor so to avoid the possibility of a ruptured ear drum. There are also pressure-regulating ear plugs which decrease the pain and are sold at most drugstores.

4. Blood clots in the legs (Deep vein thrombosis).
Please read this link for instructions on staying well hydrated and how to exercise the legs to avoid these clots which can lead to serious complications and even death.

5. Stress/fear of flying.
-- Relaxation techniques. Close your eyes and breathe in slowly through your nose and then slowly breathe out through your mouth. Repeat for 10 minutes. Picture yourself in a place such as a tropical beach and concentrate on relaxing each part of your body individually such as hands, arms, shoulders, back, stomach, legs, etc.
-- Anti-anxiety medications such as Ativan (lorazepam) or Klonipin (clonazepam) may be more immediately effective if your symptoms are so consult your doctor about these medications.

6. Dry eyes/contact lens.
Frequently apply wetting solutions to the eyes. You may also consider carrying an antibiotic eye drop containing a quinolone such as Cipro or Levofloxacin.

7. Heart burn.
Large meals followed by prolonged sitting and an increase in gas can worsen esophageal reflux. Over the counter medications such as Pepcid, Zantac, or Prilosec help relieve the symptoms. Ideally they should be taken before the meal. Maalox and Mylanta are faster but shorter acting and may be taken after meals. Try to eat small but more frequent meals or snacks. Avoid alcohol and caffeine.

On arrival:

1. Jet lag.
It can take 1 day to recover for each time zone that is crossed. Most commonly prescribed medication to help with sleep is Ambien. Melatonin may also be used but its effects are not as guaranteed. It is taken 5 mg per day at 6 pm starting 3 days before travel and continuing for a total of 7 days. Bright light therapy may be helpful as well.

2. Safe Food and Water.
The CDC has a detailed site on this subject. Please see the above link. The basic rules are drink bottled water, and don't eat it if you can't boil it or peel it.

3. Diarrhea.
Most common type of illness encountered. A general recommendation is that if diarrhea occurs, let it pass during the first 24 hours. However, if the diarrhea lasts more than 24 hours or if it is associated with blood or fever, then take the antibiotics such as Cipro.

3. Altitude sickness.
Symptoms include headache, fatigue, and insomnia. These may occur at any altitude above 5000 feet, but are more common at 8000 feet. The definitive treatment is to descend, but there are medications such as Diamox which may help relieve the symptoms.

4. For Medical emergencies.
-- The International Association for Medical Assistance to Travellers (IAMAT) publishes a booklet listing English speaking doctors and facilities worldwide.
-- The Bureau of Consular Affairs website (http://www.travel.state.gov/) has a list of doctors and facilities compiled by embassies in different countries.
-- Of course the local hotels can refer you as well.

5. What about the bird flu?
In general, your risk of exposure is very low as long as you avoid bird markets or any other areas which are high in bird feces. It is safe to eat well cooked poultry. Read here for bird flu basics. There are no vaccines for bird flu yet.

6. Do I really have to take the malaria pills?
Yes, if you are traveling to a high risk area - listed from highest to lowest risk areas - Sub-Saharan Africa, Oceania, India, Southeast Asia or Latin America. Although Sub-Saharan Africa is visited by less than 2% of U.S. travelers, this region accounts for 80% of malaria cases reported among U.S. travelers. The CDC reported a 25% increase in cases of malaria in Americans from 1998 to 2000. Throughout history malaria has killed more people than all wars and plagues combined.

Helpful websites:

Traveler's Health
MD Travel Health
WHO on International Health

References: Please see above links. International Travel Health Guide.

Accidental Overdose

2007-03-26T21:47:00.000-07:00

Anna Nicole Smith's autopsy report declared that her death was due to accidental overdose. Unfortunately according to a report in the February 2007 issue of MMWR, deaths from unintentional poisoning in th US is second only to motor-vehicle crashes as a cause of death from unintentional injury. There has been a substantial increase in death rates from accidental poisoning over the last several years. According to the Center for Disease Control, there has been a 62% increase in unintentional posioning mortality in the 5 years from 1999 to 2004. This trend may be due to greater use and abuse of narcotic medications such as oxycodone as well as psychotherapeutic medications such as sedatives.

Any death is a tragedy, let alone one that is accidental and avoidable. It is important to be aware of the correct dosage of any medication that you may be taking as well as any drug interactions when you are on multiple medicines. Please discuss all medication use with your doctors.

Why Aerobic Exercise Helps the Heart

2007-03-22T20:30:00.000-07:00

A question that I frequently get from Googlers is WHY? I often recommend exercise for cardiovascular health because the evidence shows that aerobic exercise helps the heart, but when asked why I haven't been able to give a satisfactory answer. We have never really understood how this process works other than the secondary effects of lowering the blood pressure and weight.

Fortunately thanks to Dr. Richard Sloan of Columbia University I can offer more detail on this subject. A recent study by Dr. Sloan showed that aerobic exercise decreases inflammation. Inflammation is involved in the formation of the fatty build-ups in the arteries which lead to heart disease.

In this 12 week study, blood samples were analyzed from 46 healthy adults ages 20 to 45 years old before and after the subjects exercised at moderate or high intensity. The samples were then stimulated with a bacteria and then examined for tumor necrosis factor (TNF) which is an indicator of the inflammatory process. There was a significantly lower level of TNF in the blood samples of subjects who exercised.

It remains to be seen if the results can be replicated in a larger group of volunteers and if a lower TNF can be associated with a lower risk of heart disease in a long term study.

It is reported that 70 percent of Americans do not exercise regularly.

Helping You Eat Your Fruits and Veggies

2007-03-19T20:36:00.000-07:00

Healthy People 2010 objectives include increasing the number of people who are eating fruits and vegetables since there is significant evidence that proper nutrition may help decrease the risk of certain cancers and cardiovascular disease. As part of this campaign, here are a few good websites that hopefully will encourage you to eat more fruits and vegetables. They have lots of good tips and recipes, and help determine the amount of fruits and vegetables that is recommended for any age, sex, and physical activity level.

http://www.5aday.gov
http://www.fruitsandveggiesmorematters.org
http://www.eatright.org

Photo: courtesy of discovery.com

Quick Fix for Sweaty Armpits

2007-03-14T23:39:00.000-07:00

Excessive sweating can be an annoying if not embarrassing. If antiperspirants are failing you then ask your doctor about Drysol or aluminum chloride hexahydrate. This is a topical prescription medication that is effective in reducing excessive sweating in 80% of the cases.

Drysol 20% is applied to dry skin at bedtime. Do not apply to broken or irritated skin. The next morning wash the area gently to remove any residual, then towel dry the area. Do not use any other deodorant. Repeat for 2-3 nights and then can apply once or twice a week. Any itching or tingling that occurs will subside after a few days.

Resources: International Hyperhidrosis Society
Photo: courtesy of hyperhidrosis.